GANGLIOSIDE-KLH CONJUGATE VACCINES WITH QS-21

Abstract: This invention provides a vaccine for stimulating or enhancing the production of an antibody which recognizes a ganglioside in a subject to which the vaccine is administered. The vaccine is comprised of an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject. The vaccine is further comprised of an adjuvant and a pharmaceutically acceptable vehicle. The invention also provides a method of using the vaccine for treating or preventing cancer wherein gangliosides are on the surface or in the stroma of the cancer cells.

Description: Gangiioside- LH Conjugate Vaccines with QS-21 This invention was made with support under Government Grant No. R01 CA40532. Accordingly, the U.S. Government has certain rights in the invention. Background of the Invention Gangliosides are sialic acid containing glycosphingolipids composed of a complex carbohydrate moiety linked to a hydrophobic ceramide portion. Embedded within the outer leaflet of the cell membrane, the carbohydrate chain is exposed to the extracellular matrix. Qualitative and quantitative changes in ganglioside composition during cell differentiation and proliferation have been observed and seem to reflect the state of malignant transformation of cancers of neuroectodermal origin (Hakomori 1985) . Malignant melanoma cells express a variety of complex gangliosides in addition to GM3, the major ganglioside in normal melanoctyes (Carubia et al. 1984) . Altered ganglioside metabolism in melanoma causes additional expression of GD3, GD2, GM2, 9-0-Acetyl-GD3 and GT3 (Hamilton et al. 1993; Tsuchida et al., 1987). Treatment of patients with anti-GD3 monoclonal antibodies resulted in inflammation at the tumor site and partial regression of metastasis was seen occasionally, suggesting, that gangliosides are suitable targets for immune attack (Houghton et al. , 1985) . The generation of human MAb's reactive with GD3 from melanoma patients (Yamaguchi et al., 1987) support the idea, that gangliosides are potential immunogens as well. In studies .aimed at inducing a humoral response against gangliosides in melanoma patients by active immunization, GM2/BCG vaccines seemed to be most effective (Livingston et al., 1987; Livingston et al., 1989). In a randomized study with 122 melanoma patients, who were disease-free after surgery, that it was showed that, out of 64 patients treated with BCG alone and 58 patients with GM2/BCG, the majority of patients (86%) receiving the GM2 vaccine produced antibodies. Patients that produced anti-GM2 antibodies had a significantly longer disease free and overall survival than antibody negative patients. Comparing the two arms of the trial, patients receiving the GM2/BCG vaccine had a 17% improvement in disease-free interval and 9% improvement in survival when compared to the BCG control group, though neither result was statistically significant (Livingston et al., 1993a). Unfortunately, the immune response was only of short duration, mostly IgM and of moderate titer. This suggested that GM2 was recognized as a T-cell independent antigen as a consequence of carbohydrate antigens (Livingston et al., 1989) and also because gangliosides are auto antigens expressed on some normal tissue (Hamilton et al., 1993). Similar approaches with GD2 and 9-0-Acetyl-GD3 vaccines in patients resulted in occasionally low titers and no antibody response against GD3 could be detected (Livingston, 1991) . New potent adjuvants were able to enhance the immune responses against gangliosides in some cases, but especially for auto antigens such as for tumor associated gangliosides a different approach had to be utilized. Based on Landsteiner's classical experiments (Landsteiner and Chase, 1942) with hapten-carrier conjugates, covalent attachment of poorly immunogenic antigens to immunogenic carrier proteins has been successfully used to enhance immune response. For example responsiveness to carbohydrates, other than gangliosides, could be accomplished with conjugation to appropriate carrier proteins. Coupling of bacterial capsular polysaccharides to immunogenic proteins showed a significant increase in immune response and protection (Eskola et al., 1990). Recently, vaccination of ovarian cancer patients with synthetic Thompson Friedenreich tumor antigen conjugated to keyhole limpet hemocyanin elicited humoral IgM and IgG response (MacLean et al., 1992). The important finding common in these studies was the isotype switch from a IgM response of short duration to a long lasting, high affinity IgG response indicating that activation of T- cell dependent pathways against carbohydrates is likely to occur. This approach is now applied to the melanoma tumor antigen GD3 to develop a method to synthesize ganglioside-protein conjugate vaccines and examine the immunogenicity of different GD3-protein conjugates in mice. finiwmarv of the Invention This invention provides a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle. This invention also provides a method for stimulating or enhancing in a subject production of antibodies which recognize a ganglioside comprising administering to the subject an effective dose of a vaccine for stimulating or enhancing in a subject to which the vaccine iε administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle. Brief Description of the Figures Figure 1 The Synthesis of GD3 protein conjugates after ozone cleavage and reductive amination. Insert represents HPTLC of GD3 before (A) and after (B) the cleavage. Figures 2A and 2B Time course of GD3-KLH antisera IgM (a) and IgG (b) antibodies. Each symbol on the figure represents a mouse. Figures 3A and 3B Immune thin layer chromatography of three mouse antisera after vaccination with GD3-KLH. Reactivities of IgG (a) and IgM (b) antibodies were tested on A, human brain gangliosides, B neuroblastoma gangliosides, C, melanoma ganglioside and D, GD3 antigen. Figure 4 Immunoblot of four different mice to show the specificity of the immune response. Pure ganglioside are dot-blotted and incubated with sera from mice. Figure 5 Representative FACS analysis of mouse serum reactivity prior to (peak at 3) and after (peak at 50) immunization with G D3 -KLH and QS-21 tested on melanoma cell line SK-MEL-28 Figures 6A and 6B Time course of GM2-KLH antisera IgM (a) and IgG (b) antibodies. Each symbol on the figure represents a patient. Figure 7 Detection of GM2 antibody in sera from patients vaccinated with GM2 conjugate vaccine plus adjuvant by dot blot immune staining. Ganglioside standards were spotted on nitrocellulose strips (indicated on the vertical axis) and allowed to react with prevaccination and peak titer postvaccination sera from individual patients and peroxidase-labeled goat anti-human IgM or IgG antibody. Strips are graded on a scale from 0 to 3+. MAb 696 was used aε poεitive control for GM2. Figures 8A-1 and 8A-2 Specificity of peak titer sera from patients immunized GM2-KLH + QS-21 vaccine determined by immune thin layer chromatography as described previously (3, Reference of the Third Series of Experiments) . GM2 (A) and melanoma tissue ganglioside extract (B) were applied to TLC plates, incubated with sera from individual patients and stained with peroxidase-labeled goat anti-human IgM or IgG antibody. MAb 696 was used as positive control for GM2 and resorcinol stain for gangliosides. Figure 8B Inhibition of IgG reactivity of patient serum against GM2 and GD2. GM2 (A) and melanoma tissue ganglioside extract (B) were applied to HPTLC plates, incubated with serum from patient No. 2 and stained with peroxidase-labeled goat anti-human IgG antibody. 3ml Patient serum at a dilution of 1:50 was preincubated with either 150μg GM2 or 150μg GD2 prior to immune staining. Figures 9A and 9B IgM and IgG antibody responses in melanoma patients after immunization with GM2-KLH plus QS-21 vaccines. Sequential results for six patients receiving the 100 ug QS-21 dose are shown in Figure 9a and for six patients receiving the 200 ug dose in Figure 9b. Note that one patient in each group received only four vaccinations and was taken off study due to disease progression. Arrows indicate the time of cyclophosphamide (Cy) and GM2-KLH plus QS-21 vaccine injections. Figures 10A and 10B Detection of GM2 antibody by dot blot immune staining with sera from ten patients vaccinated with GM2-KLH. Ganglioside standards were applied to nitrocellulose strips (as indicated on the left) and incubated first with sera and then, after washing, with peroxidase labelled goat anti-human IgM or IgG antibody. Results with sera from two patients from each of the five groups receiving different QS-21 doses (as indicated at the top) are shown. Pre- (a) and post-immunization (b) sera are shown for each patient. Murine monoclonal antibodies 696 and 3F8 are IgM and IgG antibodies (respectively) against GM2 and GD2. IgM antibody against GM1 was detected in sera from most patients before and after vaccination. IgM and IgG antibody against GM2 was not detected before vaccination in any of these patients. After vaccination IgM and IgG antibodies were detected against GM2 in sera from all patients. Reactions were graded 0, 1+, 2+ or 3+. An example reaction grading for this assay is: Patient 1 (100 ug QS-21) IgM (pre/post vaccination) : KLH 1+/2+, GM3 0/0, GM2 0/3+, GM1 1+/1+, GD3 0/0, GD2 0/1+, GDlb 0/0. Figures 11A and 11B IgM antibody responses in melanoma patients after immunization with the GM2/BCG vaccine. Sequential results for five patients treated during the initial four months of the protocol (group A) and five patients treated during the final four months of the protocol (group B) are shown. Arrows indicate time of cyclophosphamide (Cy) and GM2/BCG vaccine injections. Figure 12 Detection of GM2 antibody by dot blot immune staining in sera from ten GM2/BCG vaccinated melanoma patients. Ganglioside standards were applied to nitrocellulose strips (aε indicated on the left) and incubated first with sera and then after washing incubated with peroxidase labelled goat anti-human IgM antibody. GM2-MEL indicates purified GM2 extracted from melanoma biopsy samples, all other gangliosides including GM2 were derived from bovine brain. Patient numbers (6 to 58) are indicated, and pre- (a) and post- (b) immunization sera are shown for each patient. 696 and 3G6 are IgM murine monoclonal antibodies against GM2 and GD2 respectively. GM2 antibody was detected in post vaccination sera from these 10 patients. GM1 antibody was seen in pre- and post-treatment sera from patient 53 and in the post treatment serum from patient 57. Reactions were graded 0, 1+, 2+, or 3+. Examples of reaction gradings are as follows: patient 8: GM2 3+, GM2-MEL 2+; patient 54: GM2 3+, GM2-MEL 1+ and patient 57: GM2 3+, GM2-MEL 3+. The lower reactivity againεt GM2-MEL compared to GM2 seen with post vaccine sera and murine monoclonal antibody 696 reflectε a lower quantity of GM2-MEL ganglioside applied to the strips. Figure 13 Kaplan-Meier plots of disease-free and overall survival of patients with post vaccination GM2 antibody production. Patients were categorized as positive if GM2 reactivity was a) 2+ or 3+ by dot blot with an ELISA titer > 1/20 or b) 1+ by dot blot with an ELISA titer > . 1/80. Figure 14 Kaplan-Meier plots of disease-free and overall survival of 59 patients randomized to receive BCG and 57 patients randomized to receive GM2/BCG, excluding six patients who produced GM2 antibody prior to immunization (five in the BCG arm and one in the GM2/BCG arm) . Figure 15 Kaplan-Meier plots of disease-free and overall survival of 64 patients randomized to receive BCG and 58 patients randomized to receive GM2/BCG. Figure 16 Kaplan-Meier plots of disease-free survival of 59 GM2 antibody- negative patients randomized to receive BCG (Δ or A) compared to 57 GM2 antibody-negative patients randomized to receive GM2/BCG (D or ■) . Patients are stratified into two groups, patients with a single positive lymph node (Δ or D) and patients with two or more poεitive lymph nodes (A or I) . Detailed Description of the Invention Throughout this application, various references are referred to within parentheses. Disclosures of these publications in their entireties are hereby incorporated by reference into this application to more fully describe the state of the art to which this invention pertains. Full bibliographic citation for these references may be found at the end of this application, preceding the claims. This invention provides a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, compriεing an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle. The oligosaccharide portion of a ganglioside may be derived by cleaving a ganglioside or it may be synthesized directly. As used herein, an immunogenic protein is a protein that, when conjugated to the ganglioside or oligosaccharide portion thereof, stimulates or enhances antibody production in the subject. In an embodiment of this invention, the subject is a human. This invention also provides the above-described vaccine wherein the ganglioside or oligosaccharide portion thereof is conjugated to Keyhole Limpet Hemocyanin or a derivative of Keyhole Limpet Hemocyanin. Keyhole Limpet Hemocyanin is a well-known protein. A derivative of Keyhole Limpet Hemocyanin may be generated by direct linkage of at least one immunological adjuvant such as monophospholipid A or non-ionic block copolymers or cytokine with Keyhole Limpet Hemocyanin. Cytokines are well known to an ordinary skilled practitioner. An example of cytokine is interleukin 2. There are other known interleukinε in the art which may be linked to Keyhole Limpet Hemocyanin, forming a derivative of Keyhole Limpet Hemocyanin. In an embodiment of the above-described vaccine the adjuvant is QS-21. There are other known adjuvants which may be applicable to this invention. There may be classes of QS-21 or QS- 21 like chemicals which may be similarly used in accordance with this invention. This invention further provides the above-described vaccine wherein the ganglioside is selected from the group consisting of GM2, GM3, GD2, GD3, GD3 lactone, O- Acetyl GD3 and GT3. In one of the preferred embodiments of this invention, the ganglioside is GM2. In another embodiment, the ganglioside is GD3. In another embodiment, the ganglioside is GD2. Different effective amounts of the conjugated ganglioside or oligosaccharide portion thereof may be used according to this invention. A person of ordinary skill in the art can perform simple titration experiments to determine what the effective amount is required for effective immunization. An example of such titration experiment is to inject different amounts of the conjugated ganglioside or conjugated oligosaccharide portion thereof to the subject and then examine the immune response. In an embodiment, the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is an amount between about 1 μg and about 200 μg. In another embodiment, the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is an amount between about 50 μg and about 90 μg. In an embodiment, the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is about 70 μg. In another embodiment, the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is between about 1 μg and about 10 μg. In a more specific embodiment, the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is between about 7 μg and about 10 μg. In an embodiment, the effective amount of conjugated ganglioεide or conjugated oligoεaccharide portion thereof is about 7 μg. In addition, the effective amount of the adjuvant may also be similarly determined i.e. administering different amount of the adjuvant with the conjugates and examining the immune response so aε to determine which amount is effective. When using QS-21 as adjuvant, the effective amount of QS-21 may also be similarly determined. In a preferred embodiment, the effective amount of QS-21 is an amount between about lOμg and about 200 μg. In an embodiment, the effective amount of QS-21 is about 100 μg. In another embodiment, the effective amount of QS-21 is about 200 μg. This invention further provides a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle, wherein the subject is afflicted with cancer and the antibody produced in the subject upon administration of the vaccine effectively treats the cancer. This invention also provides a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioεide, compriεing an amount of ganglioεide or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle, wherein the subject is susceptible to cancer and the antibody produced in the subject upon administration of the vaccine effectively prevents the cancer. This invention further provideε a vaccine for cancers, wherein cells of the cancer have gangliosides on their surface. Thiε invention also provideε a vaccine for cancers, wherein gangliosides are found in the stroma of the of the cancer. This invention provides a vaccine for cancers which is of epithelial, mesodermal or neuroectodermal origin. Examples of epithelial cancers are breast cancers and endometrial cancers of the uterus. An example of a mesodermal origin cancer is sarcoma. One example of a neuroectodermal origin cancer is a melanoma. This invention also provides a method for stimulating or enhancing in a subject production of antibodies which recognize a ganglioεide comprising administering to the subject an effective dose of a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle. In an embodiment of the above-described method, the ganglioside is GM2. This invention further provides a method for treating cancer in a subject afflicted with cancer comprising administering to the subject an effective dose of a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to εtimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle, wherein the εubject iε afflicted with cancer and the antibody produced in the εubject upon administration of the vaccine effectively treats the cancer. This invention further provideε a method for preventing cancer in a subject susceptible to cancer comprising administering to the subject an effective dose of a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle, wherein the subject iε susceptible to cancer and the antibody produced in the subject upon administration of the vaccine effectively prevents the cancer. This invention also provides a method of uεing the above- deεcribed vaccine, wherein the ganglioside or oligosaccharide portion thereof is conjugated to Keyhole Limpet Hemocyanin or a derivative of Keyhole Limpet Hemocyanin. Thiε invention further provides a method of uεing the above-described vaccine wherein the adjuvant is QS-21. This invention further provideε a method of using the above-described vaccine for treating or preventing cancer, wherein cells of the cancer have gangliosides on their surface. Thiε invention further provideε a method of uεing the above-described vaccine for treating or preventing cancer, wherein gangliosides are found in the stroma of the cancer. This invention further provides a method of using the above-described vaccine for treating or preventing cancer, wherein the cancer is of epithelial origin or neuroectodermal origin. One such cancer of neuroectodermal origin is a melanoma. For the purposes of this invention "pharmaceutically acceptable vehicles" means any of the standard pharmaceutical vehicles. Examples of suitable vehicles are well known in the art and may include, but not limited to, any of the standard pharmaceutical vehicles such as a phosphate buffered saline solutions, phosphate buffered saline containing Polysorb 80, water, emulsions such aε oil/water emulεion, and variouε type of wetting agentε. The vaccine of thiε invention may be administered intradermally, subcutaneously and intramuscularly. Other methods well known by a person of ordinary skill in the art may also be used. In a preferred embodiment this invention provides a method for stimulating or enhancing in a subject production of antibodies which recognize a ganglioside comprising administering to the subject an effective dose of a vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle, wherein the administering comprises administering the effective dose at two or more sites. "Administering the effective dose at two or more sites" means that the effective dose is divided into two or more portions and each portion is administered at a different site of the subject. In a specific embodiment, the administering compriseε administering at three εites. This invention will be better understood from the Experimental Details which follow. However, one skilled in the art will readily appreciate that the specific methods and results discussed are merely illustrative of the invention as described more fully in the claims which follow thereafter. Experimental Details First series of experiments EXPERIMENTAL DETAILS Increased immunogenicity of GD3 conjugate vaccines: Comparison of various carrier proteins and selection of GD3-KLH for further testing. Tumor associated gangliosides are known to be suitable targets for immune attack againεt cancer but they are poorly immunogenic. Active immunization results in low titer antibody IgM responεes of short duration. Covalent attachment of poorly immunogenic antigens to immunogenic carrier proteins is a potent method for enhancing the humoral responεe. GD3, a dominant ganglioεide on malignant melanoma, was attached to carrier proteins by two methods. It was bound by the glucose of GD3 oligosaccharide but this resulted in loss of antigenicity and induction of antibodies that failed to react with GD3 or GD3 expressing melanoma cells. In the second method GD3 was modified by ozone cleavage of the double bond in the ceramide backbone, an aldehyde group was introduced and this group waε coupled by reductive amination to aminolysyl groups of proteins. Utilizing this method, conjugates were constructed with synthetic multiple antigenic peptides (MAP) expreεεing repeats of a malaria T-cell epitope, outer membrane proteins (OMP) of Neisseria meningitidis, cationized bovine serum albumin (cBSA) , keyhole limpet hemocyanin (KLH) and polylysine. The antigenicity of conjugates was confirmed by reactivity with various antibodies and the immunogenicity was tested in mice. Antibody levels in immune sera were analyzed by ELISA and by dot blot immune stains on purified gangliosideε. Specificity of sera reactivity was further analyzed by immune thin layer chromatography using tumor tissue extracts. GD3 conjugate vaccines resulted in significantly improved antibody responseε, especially with GD3-KLH conjugates. High titer IgM and IgG responεeε againεt GD3 were induced. This method is applicable to other gangliosideε and may be suitable for construction of ganglioside vaccines against a variety of ganglioside rich human cancers. Materials and Methods Glycoljpids. GM3, GM2 and GDlb and extracted from bovine brain, were provided by Fidia Research Laboratory (Abano Ter e, Italy) . GD2 was made from GDlb by treatment with β-galactosidase (Cahan et al., 1982). GD3 (mel) waε isolated from human melanoma tisεue (Ritter et al., 1991) , GD3 (bbm) (used for vaccine preparation) and GT3 were isolated from bovine buttermilk and kindly provided by Dr. R. K. Yu (Medical College of Virginia, Richmond, VA) (Ritter et al., 1990a). Disialyllactose (GD3 oligosaccharide) was isolated from bovine colostrum as previously described (Nicolai et al., 1978). Chemicals. HPTLC silica gel plates were obtained from E. Merck (Darmstadt, FRG) ; Sep-Pak C18 cartridges from Walters Associates (Mildford, MA) ; 4-chloro-lnaphtol, p- nitrophenyl phosphate disodium, sodium cyanoborohydride from Sigma Chemical Co. (St. Louis, MO) ; cyclophosphamide (Cytoxan) from Mead Johnson (Syracuεe, NY) ; QS-21 containing a εaponin Quil A component from Cambridge Biotech (Worcester, MA) . Proteins. Poly-L-lyεine hydrobromide (MW(viε)3800) was purchased from Sigma; Keyhole limpet hemocyanin (KLH) from Calbiochem (LaJolla, CA) ; cBSA-Imject Supercarrier Immunemodulator from Pierce (Rockfort, IL) ; Neisseria meningitidis outer membrane proteins (OMP) were kindly provided by Dr. M. S. Blake (Rockefeller University, New York, NY) . Multiple Antigenic Peptide (MAP) YAL-IV 294- I containing 4 repeat of a malarial T-cell epitope was a gift from Dr. J. P. Tarn (Rockefeller University, New York, NY) . Monoclonal Antibodies. Rabbit anti-mouse immunoglobulins conjugated to horseradiεh peroxidase for ITLC, and rabbit anti-mouse IgM and IgG conjugated to alkaline phosphatase for ELISA, were obtained from Zymed (San Francisco, CA) ; anti-GD3 mAb R24 was generated (Houghton et al., 1985). Serological Asεavε. Enzyme-linked Immunosorbent Assays (ELISA) were performed as previously described (Livingston et al., 1989). To control for nonspecific "stickiness", immune sera were also tested on plates which were processed identically but to which no ganglioside had been added, and the reading was subtracted from the value obtained in the presence of ganglioside. The titer was defined as the highest dilution yielding a corrected absorbance of 0.l or greater. Immunostaining of gangliosideε with monoclonal antibodies or mouse sera was performed after separation on high performance thin layer chromatography (HPTLC) silica gel glass plates aε previouεly deεcribed (Hamilton et al., 1993). Plates were developed in solvent 1: chloroform/methanol/water (0.25% CaCl 2 )50:40:10 (v/v) or solvent 2: ethanol/n-butanol/pyridin/water/acetic acid 100:10:10:30:3 (v/v) and were visualized with resorcinol/HCl reagent as well. Immunization. Six-week-old female BALB/c x C57BL76 Fl mice (The Jackson Laboratory, Bar Harbor, ME) were given i.p. injections of cyclophosphamide (15 mg/kg) 3 days before the first immunization and randomly assigned to treatment groups. Groups of 4 or 5 mice were given s.c. injections of a give three vaccines 2 weeks apart if not otherwise indicated. Each vaccine contained 20 ug GD3 or 15 ug Disialyllactose plus 10 ug QS-21 in a total volume of 0.1 ml PBS/ mouse. Mice were bled from the retro- orbital sinus before and 2 weeks after the vaccine if not otherwise indicated. GD3 conjugate preparation. GD3 (2 mg) was dissolved in 2ml methanol by sonication and cooled to -78C in an ethanol/dry-ice bath. Ozone waε generated in a ozone generator (Del Induεtrieε, San Luiε Obispo, CA) and was conducted through the sample for 30 minuteε under vigorouε stirring (Criegee, 1957; Wiegandt and Baschang, 1965) . Excess of ozone was displaced with nitrogen during 10 minutes. 100 ul S(CH 3 ) 2 waε added (Pappaε et al., 1966), the sample kept at -78°C for 30 min, then at room temperature for 90 min under vigorous stirring. The sample was dried under a stream of nitrogen and monitored by HPTLC. The long chain aldehyde was separated by adding 2 ml n-hexane to the dry sample, followed by sonication for 5 min and centrifugation at 2000 g for 15 min. The n-hexane was carefully drawn off and discarded, and the sample was dried under a stream of nitrogen. Cleaved GD3 and native GD3 were separated by HPLC (Waters, Syεtem 501, Milford, MA) utilizing a C18 reversed phase column (10 x 250 mm, Rainin Instruments, Ridgefield, NJ) . Gangliosides were eluted with methanol, monitored at 214 nm and fractions were analyzed by HPTLC as well. Fractions that contained cleaved GD3 were combined and were evaporated at 37°C with a rotavapor (Buchi, Switzerland). Cleaved GD3, protein carrier in PBS and 2 mg sodium cyanoborohydride were incubated under gentle agitation at 37°C for 48 h. After 16 h another 1 mg NaCNBH 3 was added. The progress of coupling was monitored on HPTLC. In solvent 1 and εolvent 2 GD3- protein conjugateε did not migrate and appeared aε a resorcinol positive band at the origin. The mixture was dialyzed acrosε 1000 MWCO dialysis tubing with three changes of each 41 of PBS at 4°C for 48 h and were passed through an Extractigel detergent removing gel (Pierce) for final purification of unconjugated GD3. The samples were lyophilized and their protein and ganglioside content was determined by Biorad protein assay and by neuraminic acid determination according to Svennerholm (1957) . Disialyllactose was isolated from bovine colostrum as described previously (Nicolai et al., 1978). The carbohydrate was attached to protein by reductive a ination (Gray, 1974) 10 mg disialyllacotse was incubated with 2mg of proteins in 2ml PBS for 14 days at 37°C. 2mg sodium cyanoborohydride was added at the beginning and lmg waε added additional every 3 dayε. The coupling was monitored by HPTLC in solvent 2. The disialyllactose conjugates were purified by dialysis across 1000 MWCO dialysiε membrane followed by lyophilization. The protein and neuraminic acid content waε determined as described above. Disialyllactose was also conjugated to proteins according to a method described by Roy and Laferriere (1990) . During thiε procedure N-acroloyled glycopyranosylamine derivatives of the oligosaccharide were formed first, followed by conjugation via Michael addition to amino groups of the protein. Purification and protein and neuraminic acid determination was performed as described above. Determination of IgG subclass. The determination of IgG subclass was performed by ELISA using subclass-specific secondary MAbs. Secondary Mabs were used at lowest dilution that did not show reactivity with presera or negative control sera. Alkaline phosphatase conjugated to goat anti-mouse was used aε third antibody at a dilution of 1:200. FACS Analysis of Mouse Antisera A single cell suspension of the melanoma cell line SK- MEL-28 was obtained after treatment with 0.1% EDTA in PBS followed by passage through a 26^ gauge needle. Cells (3xl0 5 ) were incubated with 40 μl of 1:20 diluted post- or pre-immunization serum for 30 minutes on ice. The cells were washed three times with 3% fetal calf serum in PBS. Thirty .μl of diluted (1:50) fluorescein isothiocyanate-labeled goat anti-mouse IgG (Southern Biotechnology Associates Inc., Birmingham, AL) were added as secondary antibody, followed by incubation ice for 30 min. Cells were washed three times as above and resuspended in 500 μl 3% fetal calf serum in PBS and analyzed by flow cytometry (FACScan, Becton Dickinson, San Jose, CA) . RESULTS Preparation and characterization of GD3 vaccineε GD3 from bovine buttermilk waε εelectively cleaved at the C4-C5 double bond in the ceramide portion by using ozone. In methanol, methoxyperoxides appear to be intermediate productε which are readily reduced with dimethylsulfite. The result of this cleavage was a GD3 derivative with an aldehyde functional group at the position of the former double bond in the ceramide portion and the elimination of a long chain aldehyde (Fig. 1) . Successfully cleaved GD3 migrated below native GD3, and due to simultaneously cleaved unsaturated fatty acidε it appeared aε a double band on HPTLC (εee HPTLC, insert in Fig. l) . Densitometric determination of HPTLC revealed a cleavage of >70% of GD3 iεolated from bovine buttermilk. Initial experiments with prolonged ozone treatment periods did not change the ratio, indicating that -30% of GD3 from this source consiεt of sphinganin or phytosphingosine analogs. Cleavage of GD3 at -78°C with a reaction time of up to lh depending on the amount of GD3 used, was found to be optimal. Cleaved GD3 persisted only in acidic and neutral phosphate buffers for up to 72 h but with increaεing amount of a byproduct. Due to B- elimination reactions, release of the oligosaccharide part of GD3 occurred increasingly with time as has been described earlier to take place readily at a basic pH (Wiegandt and Baschang, 1965) . The carbohydrate part released from GD3 did not migrate in solvent l but did comigrate with disialyllacotse isolated from bovine colostrum in solvent 2 used for separation of oligosaccharides (not shown) . The decreased hydrophobicity of cleaved GD3 compared to native GD3 allowed its separation by HPLC on C18 reverεed phase columns. Utilizing isocratic elution with methanol, cleaved GD3 with proteins resulted in formation of Schiff-bases between the modified ganglioεide and e- aminolysil groupε. They were reduced to form stable secondary amine bonds between the ganglioside and the protein by uεing εodium cyanoborohydride (Borch et al., 1971) . The reducing agent waε selective, and aldehyde groups were not reduced in phosphate buffers at pH=6.5- 7.5. The reaction was monitored by HPTLC and changing ration between cleaved GD3 and a resorcinol positive band that appeared at the origin was seen. This band indicated the formation of the neo-glycoconjugates. The reaction was normally completed after incubation for 48 h. at 37°C. Disialyllactose was readily removable by dialysiε, excess cleaved GD3 by pasεage through a detergent removing column. The degree of coupling waε determined by sialic acid and protein determinations. The weight ratio of GD3 to proteins in the conjugates depended on the accessibility of lysine groups in the different proteins and is given in Table 1. The average yield of GD3 coupled to proteins overall was 30%. The carbohydrate part of GD3, disialyllactose, was coupled to proteinε. utilizing two different methods. The conjugation of disialyllactose, was performed by reductive amination resulting in the open ring form of the glucose conjugated to proteins (Gray et al., 1978). The method required a long incubation period of the oligosaccharides with proteins and yields were less than 20%. The second oligosaccharide conjugation method (Roy and Laferriere 1990) resulted in a closed terminal glucose ring coupled to proteins. Table 1 Reciprocal ELISA titer against GD3 GD3/ No. of Protein Vaccine mice weight ratio IgG IgM GD3 5 — 0(5) 20(3) ,0 (2) GD3-ganglioside conjugate: GD3-KLH a 14 0.69 10240(2) 2560, ,5120(2) 1280(2) ,2560(3) ,640, ,1280(2) 320(3), ,80,40 160(2) , (2) ,0 80(3) , 20,0 GD3-CBSA 15 0.77 2560(2) , 80(2) , 320(2) , 40(2) , 160,80 20(7), (2) ,40 0(4) (4) , 20 (2) ,0(2) GD3-OMP 15 0.93 2560,80 1280, (4) ,20 320(2) , (3) ,0(7) 160(7) , 80(4) , 40 GD3-MAP 10 1 40,0(9) 160(2), 40(4), 20(3),0 GD3-Poly- 10 n.d. b 0(10) 320,160 lyεine (4) ,80, 40,20 (2),0 GD3-oligosaccharide conjugate: Disialo- 4 0.055 0(4) 160(3) , KLH C 80 Disialo- 4 0.16 20,0(3) 40,20 cBSA° (3) GD3-KLH d 4 0.25 20,0(3) 40(2), 0(2) GD3-cBSA d 4 0.34 0(4) 0(4) GD3-Poly- 5 n.d. b 0(5) 80(3), lyεine d 40(2) "KLH: keyhole limpet hemocyanin, cBSA: cationized bovine serum albumin, OMP: meningococcal outer membrane proteins, MAP: multiple antigenic peptide, Polylyεine: poly L- lyεine b n.d. : not done c open ring d closed ring Serological response against GD3 after vaccination with GD3- protein conjugate vaccines Preimmunization sera did not show IgM or IgG reactivity with GD3. Immunization with 20 ug GD3 alone or mixed with 10 ug of the adjuvant QS-21 failed to induce GD3 antibodies (Table 1) . Some groups of mice immunized with 20ug of GD3 conjugated to proteins pluε lOug QS-21 showed increased immune responses against GD3. GD3-poly-L-lysine conjugate, representing a high density of GD3 epitopes, induced a moderate titer IgM response (range 1/20-1/320) and no IgG response. GD3-conjugated to outer membrane proteins of Neisseria meningitidis (GD3-0MP) , also induced moderate titer IgM (rangl/20-1/320) and low titer IgG (range 1/20- 1/80) . Only one mouse showed high titer IgM response of 1/1280 and high titer IgG of 1/2560 after vaccination with GD3-OMP. GD3 conjugated to cationized BSA(GD3-cBSA) , showed low titer IgM by ELISA (range 1/20-1/80) and high titer IgG(range 1/20-1/2560) . The synthetic MAP peptide, containing a malarial T-cell epitope, provided 8 free aminogroups at its aminoterminal end and 4 were able to be conjugated to GD3. GD3-MAP induced low titer IgM (range 1/20-1/160) and only one mouse produced low titer IgG response of 1/40. GD3 conjugate to KLH (GD3-KLH) induced the highest response compared to other conjugates, with highest titer IgM (range 1/20-1/2560) , as well as highest titer IgG (range 1/40-1/10240) responεe. Immunization with both typeε of diεialyllactoεe protein conjugateε induced only low titer IgM that waε crosε reactive with GD3 ganglioside (range 1/20-1/160) and no significant IgG response. Specificity of GD3 reactive sera by immune thin layer chromatography Immune thin layer chromatography (ITLC) allows testing of GD3 antisera on human tissue ganglioside extracts and to determine specificity to tumor derived gangliosides. Examples of ITLCε with human tissue extracts and high titer IgM and IgG sera induced by immunization with GD3-KLH conjugate are shown in Fig. 3a and 3b. Sera were tested at a 1/150 dilution against ganglioside extract of human brain, neuroblastoma, melanoma, as well as against the immunogen GD3 (bbm) isolated from bovine buttermilk. The reactivity on ITLC was compared with resorcinol stained HPTLC which shows the total ganglioside composition found in these tissues. Normal brain predominantly contains GM1, GDla, GDlb and GTlb, while the neuroblastoma extract containε in addition the major ganglioεideε GD2 and GM2 and the melanoma extract containε mainly GM3 and GD3. IgG antisera showed specific reactivity only with GD3 in all three tissues extracts tested (Fig. 3a), as did the control mAb R24. IgM antiεera (Fig.3b) on the other hand εhowed some cross reactivity with εtructurally related gangliosides and sulfatide in brain extract. Immune responses induced by vaccination with other GD3 conjugates showed the same specific reactivity, but were weaker and more concentrated antisera had to be used (not shown) . High titer antisera identified by ELISA in mice immunized with GD3-CBSA showed high background by ITLC. A variety of blocking agents were used with these εera unsuccessfully. No specific reactivity with GD3 in tissue extract could be detected. Specificity of GD3 reactive sera by dot blot immune stainε The specificity of all high titer IgM and IgG antisera (by ELISA > 1/160) was studied with purified gangliosides GM3, GD2, GDlb, GD3 and GT3 isolated from bovine brain or buttermilk, and with GD3 isolated from human melanoma tisεue. These structurally related gangliosideε were spotted onto nitrocellulose εtripε in εimilar amountε and reacted with immune εera. A sample of dot blot immune stain experiments with εera obtained before and after immunization of mice with GD3-KLH and GD3-OMP is shown in Fig. 4. Presera did not show any reactivity with these gangliosides. Sera obtained after immunization with GD3-KLH showed specific IgM and IgG reactivity with GD3 from bovine buttermilk (the immunogen) as well as with GD3 isolated from human melanoma tissue. In some caseε croεε reactivity with GT3 was seen, a reaction observed also with the positive control mAb R24 (Houghton et al., 1985). High titer sera from mice immunized with GD3-cBSA showed only background reactivity but no specific reactivity against any ganglioside waε detected (not εhown) . Dot blot reactivity induced by other GD3 conjugateε were specific for GD3 (not shown) . The results indicate that specific high titer IgM and IgG responses can be induced in mice with GD3-protein conjugates, and that the strongest reactivity was induced with GD3-KLH conjugates. The conjugated method seems to preserve the important epitopeε on the GD3-oligosaccharide chain and GD3-conjugates did not induce cross reactivity with structurally related gangliosideε. Cell Surface Reactivity of Immune Sera Determined by FACS Analvεis: Sera from mice were teεted for binding to cellε of the melanoma cell line SK-MEL-28, a cell line known to express cell surface G D3 . A representative example of a FACS analysis utilizing a fluoreεcein isothiocyanate-labeled secondary goat anti-mouse antibody is shown in Fig. 5. Sera before and after immunization with G D3 -KLH and QS-21 were tested. Preimmunization εerum stained 8% of the target cellε, postimmunization serum 92%. DISCUSSION An approach for construction of ganglioside conjugate vaccines is described here to 1) establish a coupling reaction with proteins applicable to different tumor ganglioεideε, 2) increase the immunogenicity of GD3 as the major ganglioside asεociated with melanoma and, 3) define the most effective protein carrier. Ganglioside conjugation must be accomplished without altering the immune dominant carbohydrate moiety. It has been shown that modification of GD3 in its carbohydrate portion for example conversion of carboxyl groups to amide groups, increases the immunogenicity of the synthetic antigens but there was no significant crosε reactive antibody reεponεe with native GD3 (Ritter et al., 1990b). Consequently, this approach aimed at coupling GD3 via its ceramide portion without alteration of the carbohydrate part. The ceramide, characteristic for all gangliosides, was cleaved with ozone at the C4 position of the sphingosine baεe and a functional aldehyde group waε introduced. Coupling to proteinε waε realized by reductive amination to form a εtable amine bond between ganglioεide and e-aminolyεyl groupε of proteinε. Cleavage of gangliosides by ozonolysiε and subsequent conjugation has not yet been described and it was aεεumed that the aldehyde intermediate of ganglioεideε iε inεtable. Fragmentation has been reported, when initiated by the attack of hydroxy ions under alkaline conditions, migration of double bond occurs and β-elimination causes release of the oligosaccharide part (Kanfer and Hakomori, 1983; Wiegandt and Baschang, 1965). The aldehyde function is found to be sufficiently stable at neutral pH, Schiff baεeε with amino groups of proteins are readily formed and β-elimination occurε only to a εmall extend. An overall yield of 30% waε comparably efficient as described for the conversion of gangliosides into lyso- derivativeε (Neuenhofer et al., 1985). The aldehyde derivative of GD3 did not react any longer on immune thin layer chromatography (ITLC) with mAb R24. A εimilar phenomena haε been described in connection with the reactivity of mAb M2590 with GM3 and reactivity was dependent on the acyl chain length (Itonori et al., 1989). On the other hand, GD3 protein conjugates, showed reactivity with mAb R24 by ITLC and western blot, indicating that immune dominant epitopes were restored in the GD3 neoglycoconjugates. Once the conjugation method for generation of ganglioside vaccine established, appropriate carrier proteins had to be selected. Lowell et al. (1988) described an elegant vaccine system that induced high titer antibody responses by complexing of bacterial carbohydrate and peptide antigens via a synthetic, hydrophobic foot into outer membrane proteins (OMP) of Neisseria meningitidis and effective without additional adjuvant (Donnelly 1991) . This system was directly applicable to ganglioεides due to their amphipatic nature. In previous experiments, applicants absorbed ganglioεideε by hydrophobic interaction onto these proteins and were able to induce high titer IgM responses (Livingston et al., 1993b). Covalent attachment was utilized, but GD3-OMP conjugate induced only occaεional IgG responses and the IgM responεe did not exceed results of previous trials without conjugation of GD3. Cationized BSA, which has been reported to be a potent immune modulator for protein antigens (Apple et al., 1988), was able to enhance specific immune reεponse to poorly immunogenic proteins after conjugation. GD3-cBSA conjugates induced only moderated IgM response, but high titer IgG antibodies were analyzed by ELISA. Further examination of these high titer antisera by ITLC or dot blot immune stainε indicated that the response was not specific for GD3. Another appealing approach for vaccine construction has been described by J.Tam et al. (Tam, 1988; Tam and Lu, 1989) as a multiple antigenic peptide syεtem (MAP) . Based on an oligomeric branching lysine core, MAPs consist of four or eight dendritic peptide arms containing B-and T-cell epitopes. The immune response to peptides waε dramatically increase when these constructs were used in comparison to the peptides with B-cell or T-cell epitopes alone. When GD3 waε attached to the amino terminal end of a MAP structure, containing a malarial T-cell epitope, only moderate IgM and no IgG response against GD3 was detected. Although this approach is very effective for εynthetic peptideε it seems to be of litter use for ganglioεideε vaccines. It haε been reported, that anti gangliosideε antibodies can distinguish between tumor derived GM3 and GM3 on normal tisεue because of their different cell surface density (Nores et al. 1987) . The conjugation of GD3 to polylyεine waε thought to represents a high density of GD3 epitopes combined on a single molecule. The response to GD3-polylysine was moderate, only medium titer IgM response was detectable and no IgG response. Finally, the mice immunized with GD3 conjugated with keyhole limpet hemocyanin, GD3-KLH, were able to generate the highest titer IgM and IgG responses and significantly higher than those generated by previous vaccines. These sera when tested by immune stains assays were found to be highly specific for GD3 in human tisεue extractε. Time course experiments of the IgM immune response indicated similar characteristic as observed in previous trials (Fig.2). IgM peak titer were received after the third vaccination when administered in biweekly intervals. The response declined fast and continuous vaccination did not induce a significant boost in antibody response. This iε the first report to show induction of high titer IgG response using ganglioside vaccines. This response lasted significantly longer than IgM responεe and waε booεted by continuouε vaccination, but was not comparable to the exponential potentiation of response often seen with protein antigens. The subclass was determined as mainly IgGl and it is not clear if T-cell dependent pathways were activated with ganglioside conjugate vaccines. Although the importance of T-cell help in B-cell maturation is undoubted, the regulation of antibody claεε is controversial and several reports have shown that isotype switch is possible with T helper cell activity (Teale and Abraham, 1987) . Conjugates containing solely the oligosaccharide part of GD3 were found not to be reactive with mAb R24 and were not able to induce a significant immune response against GD3 ganglioside. Modification of the glucose at the reducing end of the oligosaccharide chain during conjugation or the missing part of the ceramide may influence the proper epitope presentation and the detection by the immune system. Both methods used for conjugation were less efficient and yields were low. The induction of a specific immune response against tumor associated gangliosides with less effective vaccines in patients induced already immune responses and were associated with better prognosis. Ganglioside conjugate vaccines showed their ability to induce long lasting and specific IgG response in mice with suggest, that especially GD3-KLH conjugate may soon prove usefulness as tumor vaccine in melanoma patientε. Second series of experiments A Phase I trial of the immunological adjuvant QS-21 in melanoma patients vaccinated with the ganglioside GM2 covalently attached to KLH. Objective: To determine the optimal safe dose of the immunological adjuvant QS-21 for induction of antibodies against GM2 BACKGROUND Patients with AJCC Stage III melanoma have a recurrence rate at two yearε and mortality rate at three yearε of 60-70% (Hilal et al. 1981; Eilber et al. 1976). Patientε with Stage IV melanoma who are free of diεease after surgery have a more ominous prognosiε. There is no treatment known to alter these rates. The standard treatment for Stage III melanoma after surgery is close observation. Some patients with melanoma have antibodies in their serum which react with highly restricted melanocyte differentiation antigens have been εhown. In εome case, it was noted that the presence of these antibodies has been associated with an unexpectedly favorable course (Livingston et al., 1987). As only few patientε have these antibodies in their serum, attempts have been made to induce antibody formation by immunizing the patientε with melanoma vaccines containing the relevant antigens. Vaccine prepared form whole cells have been ineffective in this regard (Livingston et al. 1982) . Purified antigens, rather than whole melanoma cells are now proposed for vaccine production. In recently completed trials, patients have been vaccinated with BCG-GM2 and short-lived IgM antibody production were seen in 33 of 44 patients . (Livingston et al. 1989; Livingston, 1989), but IgG antibody responses were rarely seen. Potent adjuvants or other approaches for increasing the immunogenicity of gangliosides such as GM2, and in particular for inducing an IgG response are continuously sought. It was found to be moεt succesεful at inducing an IgG response to gangliosides in the mouse by covalent attachment to keyhole limpet hemocyanin. The basis for this is the concept of split tolerance. Studies of immunological tolerance and of wayε to overcome it have εhown that in a variety of experimental systems T cell unresponsiveness is more rapidly induced and more easily maintained than B cell unresponsiveness (Romball et al. 1984; Weight, 1977). Levels of circulating antigen suitable for maintaining T cell tolerance frequently fail to maintain B cell tolerance. Consequently, if T cell help iε provided (aε by potent irrelevant antigens such aε KLH covalently attached to the deεired immunogen) , antibodieε can be induced to tolerated T cell dependent antigenε. Thiε approach haε been εuccessfully used to induce IgG antibodies against a variety of carbohydrate antigens in experimental animals (Kundu et al. 1980; Gray 1978; Chang and Rittenberg, 1981; Longenecker et al., 1987) and recently against H. Influenza Polysaccharide antigen in infants. The molecular weight of KLH iε quite variable but approximate 2 x 10 6 daltons. It has been injected intradermally in patients , by several inveεtigatorε (Berd et al., 1982) at a doεe of 1 mg to induce delayed type hypersensitivity (DTH) . Pyrogen free KLH has been prepared by Biomira Inc. (Edmonton, Canada) and covalently linked to GM2 at a high epitope density (1000/1) . High titer IgG responses against GM2 using these preparations mixed with immunological adjuvants in the mouse have been induced. Of the immunological adjuvants tested in preclinical studies with KLH-conjugate vaccines such as T antigen-KLH, QS-21 has been the most effective. IgG antibody titers over 1/4000 and potent DTH are seen in most mice. T-KLH alone results in a median titer of 1/160 with no DTH. QS-21 is a carbohydrate extracted from the bark of the South American tree Quillaja saponaria Molina. The monosaccharide composition, molecular weight, adjuvant effect and toxicity for a series of these εaponinε haε been deεcribed (Kensil et al. 1991) . QS-21 was selected due to itε adjuvanticity and lack of toxicity. It haε proven nontoxic and highly effective at augmenting the immunogenicity of an FeLV subunit vaccine in cats (Marciani et al.) and an HIV-i recombinant vaccine in Rhesus monkeys. In addition, aε it was shown that some patientε with melanoma have εuppreεεor cellε which may interfere with immunization and that theεe cellε can be inhibited by a low doεe of cyclophosphamide (Livingston et al., 1987b), each patient will receive a low doεe of cyclophosphamide prior to the first vaccination. This combined approach has been found to augment the immunogenicity of glycolipidε and other antigenε in experimental animalε and melanoma patientε (Livingston et al. 1987a; Livingston et al., 1989). Study Population Patients with high risk AJCC stage III or IV malignant melanoma two to eight monthε after surgical resection, whose pathology slides have been reviewed by the Memorial Hospital Department of Pathology, and who are clinically free of disease will be eligible. They must have a performance status of >80 (Karnofsky) and an expected survival (aside from their melanoma) of at leaεt 5 yearε. Pregnant women, patients with allergies to seafood and patientε with creatine or bilirubin > 2.0 are excluded. Patientε may have received previouε irradiation, chemotherapy or immunotherapy (completed 8 weeks prior to vaccination) . Treatment evaluation Patients must have had a thorough physical examination at Memorial Hospital and chest X-ray, CBC, serum creatinine and liver function tests within 3 weeks of treatment, patients with abnormal LFT or chest X-ray resultε are accepted if further tests (i.e. CTT, tomograms, etc.) show no melanoma. Vaccine Preparation CHEMISTRY AND MANUFACTURING DRUG SUBSTANCE NAME AND SOURCE Proper name: GM2-KLH εynthetic tumor aεεociated glycoconjugate (S-TAG) - to be used for active specific immunotherapy GM2-HSA synthetic tumor associated glycoconjugate (S-TAG) - to be used for εkin teεting of patients undergoing active specific immunotherapy with the GM2-KLH. Chemica1 name: H 3 NeuAc-GgOse 3 Cer-keyhole limpet hemocyanin (KLH) Laboratory codes : GM2-KLH Lot # 5 GM2-HSA Lot # 1 Manufacturer:Biomira Inc. Research Centre One, Edmonton Research and Development Park, 9411-20 Avenue Edmonton, Alberta T6N 1E5 Canada. MATERIALS USED FOR THE PREPARATION OF THE GM2 HAPTEN MATERIAL SUPPLIER GRADE Acetone BDH ACS Ammonia Solution BDH ACS Chloroform BDH ACS Ethanol Commercial Alcohol Ltd. Ethyl Ether BDH ACS Methanol BDH ACS 2-Propanol Fisher UN1219 ACS Water Travanol sterile water for irrigation. Calcium Chloride Fisher Certified (anhydrous - 20 mesh granular) Dimethyl Sulfide Aldrich - 99% + GM2 Fidia Oxygen Linde UN1072 UHP Silica Gel E Merck Kieselgel 60H Art 7736 Sodium Aldrich 95% Pure Cyanoborohydride TLC Plates E Merck Kieselgel 60H F254 MATERIALS USED IN THE CONJUGATION PROCEDURE MATERIAL SUPPLIER GRADE Keyhole limpet hemocyanin Calbiochem, (KLH) , lyophilized, 60% San Diego, CA protein in BES [N,N-bis- (2-hydroxyethyl) -2-aminoethano sufonic acid] buffer, purity 90% Deoxycholic acid, sodium salt Aldrich Analytical (DOC) (monohydrate) 98% Ethylenediamine tetraacetic Aldrich ACS acid di-sodium hydrogen orthophos- BDH Analytical phate (anhydrous) (Na 2 HPO Sodium chloride BDH Analytical (NaCl) Potassium dihydrogen BDH Analytical orthophosphate (KH 2 P0 4 ) Sodium hydroxide BDH Analytical (NaOH) Tris (hydroxymethyl) Sigman aminomethane hydrochloride Sodium cyanoborohydride Aldrich (NaBH 3 CN) Sepharose CL-4B Pharmacia Nitrogen gas (filtered) Medigas Human serum albumin, 25% Miles USP, For solution (HSA) injection GM2 aldehyde Biomira Inc. DEVELOPMENT CHEMISTRY Data for the GM2 and GM2 Aldehyde: The structures of GM2 and GM2 aldehyde were characterized by Biomira Inc. by H NMR spectroεcopy, thin layer chromatography (TLC) FAB-MS and FT-IR. STRUCTURAL MOLECULAR MOLECULAR FORMULA FORMULA WEIGHT GM2 - ganglioside (compound #1) GalNAcBl-4GaLBl-4 GlcBl-lCer C 67 H 121 0 26 N 3 M-l=1382 Solid Neu5Aca2 I 3 NeuAc-Gg0εe 3 Cer C 69 H 125 0 26 N 3 M-l=1410 ( acid) TLC : Rf=0 . 21 ( 65 : 35 : 8 CHCL 3 -CH 3 OH-H 2 0) Rf=0 . 60 ( 5 : 4 : 1 CHC1 3 -CH 3 OH-0 . 2 % aqueous CaCl 2 ) Rf=0. 2 (7 : 1 : 1 (CH 3 ) 2 CHOH-NH<OH-H 2 0) STRUCTURAL MOLECULAR MOL. PHYSICO-CHEMICAL FORMULA FORMULA WT. CHARACTERISTICS GM2-aldehyde C 53 Hg 3 0 27 N 3 1204.29 Cream White, (compound #2) Odorless, Amphorous Solid STRUCTURAL DATA 1 H(DMSO-d 6 :D 2 )5:9.48(d,lH,J=2,OHz) , 4.79(d,1H,J=8.5Hz, III- 1), 4.26(d,lH,J=8.0Hz,II-l) , 4.19 (d,1H,J=8,OHZ,I- l) , 2.54 (dd , lH , A-3e) , 1.88 ( ε , 3H , Ac) , 1.78(ε,3H,Ac) ,0.85(t,3H,J=6.6Hz,CH 3 ) . FT-IR (KBr Caεt, CM "1 ): 3439,3420,2952,2923,2851,1634,1070 (poεεibly the gem diol) . TLC Rf=0.5 (5:4:1 CHC1 3 -CH 3 OH-0.2% aquecous CaCl 2 ) Data for the KLH. GM2-KLH. HSA and GM2-HSA: The keyhole limpet hemocyanin (KLH) is a large, complex protein composed of a number of smaller molecular weight subunitε. The KLH is extracted and purified from the keyhole limpet mollusk (Megathura crenulata) . The KLH, HSA and the conjugateε were characterized by Biomira Inc. by Sepharose CL-4B gel filtration chromatography, isoelectric focusing (IEF) and the color metric resorcinol-hydrochloric acid method (1) . COMPOUND SEPHAROSE CL-4B ISOELECTRIC RESORCINOL-GEL CHROMATOGRAPHY FOCUSING HC1 (# moles Molecular Weight (Isoelec. pts.) moles of (daltonε) hapten/moleε of protein) KLH Whole mpl. (2) :>2xl0 6 Mult, bands Subunits: 2-7 x 10 5 between pH 4.65 and pH 6 GM2-KLH Whole mol. (2)>2xl0 6 Multiple bands Subunits: 2-7 xlO 5 between pH 4.65 200- and pH 6 1400 HSA 5-9x10* Broad band at pH 4.65 GM2-HSA 5-9x104 Broad band 2-12 at pH 4.65 1. L. Svennerholm, Biochimca et Biophysica Acta, 24. (1957), 604-611. 2. Using the Sepharoεe CL-4B gel filtration method, the whole KLH protein molecule eluteε in the void. volume of the column which indicateε that the molecular weight of KLH iε >2xl0 6 . Thiε value iε consistent with the range of weights given in the literature for this protein. GM2-KLH MANUFACTURING FLOW CHART STAGE 1 - PURIFICATION OF GM2: GM2 (FIDIA) εent for viral testing •l Silica Gel Column Chromatography 1. 65:35 chloroform - methanol 2. 65:35:4 chloroform - methanol - water 1 In-process QC: 1. TLC 2 . NMR STAGE 2 - PURIFICATION OF THE KLH: KLH dissolved in PBS pH 7.5 (-3 mg/ml) •1 Centrifuged I Sample of dissolved KLH run through Sepharose column to determine the molecular weight profile i Diafiltered v.s the following bufferε εucceεεively: 1. PBS pH 7.5 2. TRIS-HC1,EDTA pH 7.75 3. TRIS-HC1,EDTA, 0.5% DOC pH 7.75 4. TRIS-HC1,EDTA pH 7.75 5. PBS pH 7.5 I Volume adjusted with sterile, pyrogen-free PBS to - 75mL I Centrifuged Sterile Filtered I BioRad Protein Assay Performed I Sample of the KLH run through a Sepharose column to determine molecular weight profile A Concentration adjusted to 10 mg/mL with PBS pH 7.5 i KLH aliquotted in serum vials and frozen at —20±5°C •l In-process tests: 1. Isoelectric focusing (IEF) 2. Limuluε amebocyte lyεate (LAL) pyrogen teεt A STAGE 3 - SYNTHESIS OF GM2 ALDEHYDE (COMPOUND #2): GM2 (Compound #1) •I (1) 0 3 , MeoH A (2) CH 3 SCH 3 A GM2 Aldehyde (Compound #2, may be the gem diol) A In-proceεs teεtε done in-houεe: 1. TLC A STAGE 4, - CONJUGATION OF THE GM2 HAPTEN TO KLH: Sterile pyrogen free KLH thawed A KLH added to hapten in 4: 1 ratio (w/w) A Incubated at room temperature with εhaking for 3 minuteε A NaBH 3 CN is added to hapten/KLH mixture in 1:1 ratio (w/w) to hapten A Reaction mixture is gently stirred at room temperature overnight then at 40°C for 4 days A STAGE 5 - DIAFILTRATION OF THE CONJUGATE: Conjugate is diafiltered vs.: -PBS pH 7.5 -TRIS/EDTA pH 7.75 -TRIS/EDTA/0.05% DOC pH 7.75 -TRIS/EDTA pH 7.5 -PBS pH 7.5 Conjugation aεeptically removed from the Amicon filtration unit I Centrifuged A Conjugate sterile filtered A In-procesε QC teεts: 1. BioRad Protein Assay 2. Sepharose gel filtration 3. Iεoelectric focuεing (IEF) A Concentration of conjugate aεeptically adjuεted to l mg/mL A Conjugate dispensed into 1 mL sterile, pyrogen free serum and frozen at -20±5°C A Final QC testing: 1. Enzyme immunoaεεay (EIA) 5. Rabbit pyrogen test 2. LAL pyrogen test 6. General safety test 3. BioRad protein asεay 7. Sterility teεt 4. Reεorcinol-HCl aεεay 8. Impurity teεt for cyanide METHOD OF MANUFACTURE OF GM2-KLH CONJUGATES The manufacturing of the GM2-KLH semisynthetic glycoconjugate fir ASI and GM2-HSA semi-εynthetic glycoconjugate for skin testing is carried out in 5 stages: 1. Purification of incoming GM2 (bovine source) (compound #1). 2. Purification of keyhole limpet hemocyanin (KLH). 3. Synthesiε of GM2 aldehyde (compound #2). 4. Conjugation of the GM2 hapten to KLH. 5. Diafiltration of the conjugate. Stage 1: Purification to GM2 (Compound #1) : Name: GM2 ganglioside Abbreviated Name: II 3 NeuAc-GgOse 3 Cer A sample of GM2 ganglioside (bovine source) starting material supplied by FIDIA is εent for viral testing (8CFR protocol) . All glass ware is washed with distilled acetone followed by distilled ethanol and then overdrive (130°C) for 18 hours prior to use. A column (Michel-Miller S 795-10) of silica gel (30.5g, Kieselgel 60H, Art 7736, E. Merck) is packed at 75 psi (SSI Model 300 Lo pump) using 65:35 chloroform:methanol as solvent. GM2 (200 mg) is applied as a concentrated 65:35 chloroform-methanol solution and elution is performed with this solvent, followed by 65:35:4 chloroform-methanol-water. The fractions are analyzed by TLC (Rf 0.6, 5:4:1 chloroform-methanol-0.2% aqueous CaCl 2 ) . The GM2 containing fractions are pooled and evaporated to give a creamy white amorphous solid. In-procesε testing for this material (compound l includes *H NMR and thin layer chromatography (TLC) to confirm the identity and purity of this ganglioside. The in-process test results must meet the specifications listed under developmental chemistry. If this material iε found to be impure, the above purification iε repeated. Stage 2: Preparation of εterile, pyrogen-free keyhole limpet hemocyanin (KLH) Preparation of KLH: Thiε entire procedure iε carried out inεide of a Class 100 biological safety cabinet. Key hole limpet hemocyanin (KLH) supplied by Calbiochem, is dissolved in 100 mL of sterile, pyrogen-free phosphate buffered saline (PBSP pH 7.5. This solution is incubated at 2-6°C for 18 hours to allow the KLH to dissolve into solution. The solution is then spun at 200 rpm for 30 minutes. The supernatant is collected and a sample of this is run through a Sepharose CL-4B gel column to determine the molecular wight profile of the unprocessed KLH. Prior to dialysis of the KLH, the Amicon Stirred Ultrafiltration Cell is made sterile and pyrogen-free by rinsing it four times first with sterile water for injection (WFI) then filling it with 95% ethanol and letting it stir for 2 hours. The unit is again rinsed with WFI water then autoclaved. The supernatant containing the KLH is poured into the sterile, pyrogen-free 400 mL Amicon diafiltration unit with a YM 30 (30,000 molecular weight cutoff) filter. The total volume of the KLH is then brought up to 350 mL with sterile, pyrogen-free or low pyrogen content buffers succesεively: 1. 1 complete change of PBS pH 7.5 (εterile, pyrogen-free) 2. 3 complete changeε of TRIS-HC1, EDTA pH 7.65 (εterile, low pyrogen content) 3. 2 complete changes of TRIS-HCl, EDTA pH 7.75 with 0.5% Deoxycholic acid (DOC) (sterile, low pyrogen content) 4. 4 complete changeε of TRIS-HCl, EDTA pH 7.75 (εterile, low pyrogen content) 5. 3 complete changes of PBS pH 7.5 (sterile, pyrogen- free) Each buffer change consists of bringing the volume in the Amicon unit down to 50mL or less then adding buffer to raise the volume back up to 350 mL. (The sterile, pyrogen-free PBS is prepared using chemicals that are baked at 180 - 185°C for 4.5 hourε. The che icalε are added to sterile water for injection (WFI) and mixed in a sterile, pyrogen-free container. The chemicals or the other buffers cannot be baked to depyrogenate them as they melt as such extreme temperatures, therefore, these buffers are prepared in sterile WFI water in sterile, pyrogen-free containers and sterile filtered with a 0.22 μm filter. The pH of the PBS and TRIS-HCl buffers is adjusted to the required pH using sterile, pyrogen-free 2N sodium hydroxide.) The DOC in the TRIS, EDTA pH 7.75 buffer serves to break the pyrogens down into their lower molecular eight subunits which pass through the filter while the KLH protein is retained in the Amicon unit (8.9). The KLH solution is aseptically removed from the Amicon unit and spun again at 2000 rpm for 30 minutes. The solution is then transferred to a sterile, pyrogen-free graduated cylinder and the final volume is adjusted to 75 mL with sterile, pyrogen-free PBS pH 7.5. The supernatant is then sterile filtered with a 0.22 μm low protein binding filter. A sample of the KLH is run through a Sepharose CL-4B column to determine if the treatment of the KLH with the buffers (the DOC in particular) affected the molecular weight profile of the KLH compared with the initial column chromatography resultε of the untreated KLH. The profile εhould not have changed εignificantly. An aliquot iε taken of the KLH and a BioRad protein assay performed using KLH for the εtandard curve. The final volume of the KLH εolution iε aseptically adjusted with sterile, pyrogen-free PBS 7.5 to provide a final protein concentration of 10 mg/mL. An LAL test iε done to determine the level of . pyrogenε present in the purified KLH. The pyrogen content must be less than 10 EU/ g for the KLH to be used in the conjugation procedure. Isoelectric focusing (IEF) is done to check the purity and identity of the KLH. Past lots of KLH are run in parallel to act as standards. The KLH solution is dispensed in 10 mL aliquots into sterile, pyrogen-free 30 mL serum vials and capped with sterile, pyrogen-free butyl stoppers. The KLH is then frozen at —20±5°C until time for conjugation to the hapten. Stage 3: Synthesis of GM2 Aldehyde (of Gem Diol, Compound #2): All glassware is rinεed with " diεtilled methanol and overdried (130°C) for 18 hours prior to use. A solution of the purified GM2 ganglioside (compound #1) (40 mg) in distilled methanol (10 mL) is stirred at -15°C (dry ice- ethanol) and ozone gas (Orec O3V10-0 ozonator) is passed through the solution for 7 minutes. A stream of argon is then passed through the solution while the reaction is checked by TLC (5:4:1 chloroform-methanol- 0.2% aqueous CaCl 2 ) . The solvents are then removed under reduced presεure and the reεulting material iε dissolved in distilled methanol. To this solution is added methylsulfide (200 ml) and the reaction mixture is stirred at room temperature for one hour. The solvents are then removed and the residue iε triturated with ethyl ether(4 x 25 mL) . The reεulting white εolid (compound #2) iε dried in vacuo for 15 minuteε to remove any remaining εolvent and iε then used directly in the subsequent conjugation step. Due to the unstable nature of the resulting aldehyde (B- elimination) , comppund #2 is identified on a routine basis only by TLC. The TLC of a typical run generally indicates the presence of a small amount of sphinganine or phytosphingosine analog (same Rf as compound #1) and a small amount of reducing sugar (Rf 0.32). Stage 4: Conjugation of GM2 Hapten to KLH (or HSA): All manipulations are done in a Class 100 biological safety cabinet. Two vials, each containing 10 mL of the frozen sterile, pyrogen-free KLH (10 mg/mL) , are thawed at room temperature immediately before use. The KLH protein (16 mL) is aεeptically measured and added to the flask containing the lyophilized GM2 hapten and a magnetic stir bar. The solution is gently agitated at room temperature for 3 minuteε until all of the hapten haε gone into solution. The sodium cyanoborohydride (NaBH 3 CN) (40 mg) is added to the hapten/KLH solution then the flask is sealed with a stopper equipped with a sterile filter needle. The solution is gently εhaken then incubated overnight at room temperature. The εolution iε then further incubated at 40°C for 4 days. Stage 5: Diafiltration of the Glycoconjugates (GM2-KLH) : The contentε of the hapten/KLH reaction vial are aεeptically transferred to the sterile, pyrogen-free Amicon ultrafiltration unit with a YM-30 filter. Filtered nitrogen is used to provide an operating pressure of 16 psi for the Amicon unit. The conjugate is then diafiltered against the following sterile, pyrogen-free or low pyrogen content buffers successively: 1. 2 complete changes of PBS pH 7.5 (sterile, pyrogen- free) 2. 2 complete changes of TRIS-HCl, EDTA pH 7.75 (sterile, low pyrogen content) 3. 2 complete changes of TRIS-HCl pH 7.75 with 0.5% Deoxycholic acid (DOC) (sterile, low pyrogen content) 4. 4 complete changes of TRIS-HCl pH 7.75 (sterile, low pyrogen content) 5. 3 complete changes of PBS pH 7.5 (sterile, pyrogen- free) The glycoconjugate is then aseptically removed from the filtration unit and spun at 2000 rpm for 30 minutes. The supernatant is e then εterile filtered with a 0.22 mm low protein binding filter. A sample of the glycoconjugate is obtained and the following in-process QC testε are done: 1. Sepharose gel filtration 2. Isoelectric focusing (IEF) 3. BioRad protein assay Based on the resultε of the protein assay, the final volume of the glycoconjugate is adjusted with sterile, pyrogen-free pH 7.5 to yield a protein concentration of lmg/mL. Inside of a Clasε 100 biological safety cabinet, the final glycoconjugate is then dispensed in 0.5 mL aliquots with an overfill volume of 0.1 mL into 1 mL sterile, pyrogen-free, clear, borosilicate serum vials with red rubber stoppers and frozen at —20°C. During the filling procedure, the air inside the filing area is monitored by exposing two blood agar plates to the. air near the work area inεide of the hood for a minimum of thirty minuteε. These plates are then transferred to a 37°C incubator and incubated for 1-2 days. The plates are then examined for any bacterial or fungal colonies. The vials are placed inside of a box with a label indicating the product name, lot number and number of vials. The box iε then sealed and a label with the same information is placed on the outside of the sealed box. The box is then placed in Quarantine in the fridge for 1-2 days until it can be labeled. Once the final QC tests have been done, labels are requested. The product is labeled by the manufacturing personnel then the labeling is verified by the Quality Control department or the Regulatory Affairs department. The final product file is then signed off by the manager of Regulatory Affairs and by the Vice President and COO of the Immunotherapeutics division. The product is then released and stored in a "Released Product" freezer at —20°C. Each lot of GM2 - KLH and GM2 - HSA goes through the following Final Quality Control tests: 1. Enzyme Immunoassay (EIA) 2. LAL pyrogen test 3. BioRad protein assay 4. Resorcinol-HCl carbohydrate assay 5. Rabbit pyrogen test 6. General εafety test 7. Sterility test 8. Impurity testing for cyanide GM2-KLH is prepared by Biomira Inc. (Edmonton, Alberta) and used under an IND with the U.S. Food and Drug Administration. The GM2/KLH molar ratio is 800/1 (actual=200-1400) and the conjugate is supplied at a concentration of 0.57 mg conjugate per 0.5 ml phosphate buffered saline (PBS) . This represents approximately 70 ug of GM2 ganglioside and 500 ug KLH per 0.5 ml PBS. On the day of vaccination for the initial 5 immunizations, 0.5ml will be placed in an individual εyringe and brought to the clinic for ad iniεtration. Thiε represents a GM2 dose of 70 ug, a dose found effective in previous studies with GM2 plus various adjuvants. The final (sixth) immunization will contain one-half of this dose, 35ug GM2 and 250 KLH. QS-21 iε extracted by Cambridge Bioεcience Inc. (Worcester, MA) from Quillaja saponaria Molina tree bark by εilica and reverse phase chromatography as previously described (16) . The purified GM2-KLH conjugate and QS-21 are tested for εterility by standard culture techniques in the bacteriology laboratory, for pyrogenicity in rabbitε and for safety in rabbits and mice. They are aliquoted and stored at -15 to - 25°C. On the day of vaccination, 570 ug GM2-KLH (or 285ug for the sixth vaccination) is mixed with QS-21, placed in an individual syringe, labeled, and brought to the clinic. Four doses of QS-21 will be used, 10, 50, 100 and 200 ug, each diluted to a total volume of 0.25 ml in PBS. The first group of 3 patients will receive 6 vaccines containing lOug QS-21, the next 3 patients 50 ug QS-21, the next 3 patientε 100 ug QS-21 and the final 3 patientε 200 ug QS-21. No patient will be entered at the next dose until all 3 patients receiving the previouε doεe have received at leaεt two vaccinationε. If no toxicity iε seen at the 200 ug dose and if the immunological reactivity to GM2 antigen and KLH has not plateaued over the 50-200 ug range, then 3 additional patientε may be treated at a dose of 400 ug. Once a safe and maximally immunogenic dose has been identified, 6 additional patients will be immunized at that dose to better define the antibody response. The IND for the use of GM2-KLH plus QS-21 is held by MSKCC. Treatment Three to five dayε before the first immunization 200 mg/M 2 of cyclophosphamide is administered IV. This is the dose and schedule applicants have uεed εucceεsfully in past vaccine trials. Four vaccinations are then administered subcutaneously at two week intervals, beginning 2-30 weeks after surgical resection of all known disease. Two additional vaccinations are administered at two month intervals. Evaluation Serological response: The primary end point of this trial is serologic response. Peripheral blood (30ml) will be drawn immediately before each vaccination and 2 weeks and 5 weekε after the fourth, fifth and εixth vaccinations. Thereafter, blood may be drawn at 3-month intervals, as long as detectable antibody against GM2 perεists. Sera obtained 2 weeks after the fourth, fifth and sixth vaccines from all patients will be tested by ELISA for antibodies against GM2 and related gangliosides. Patients with titers of 1/80 or greater which are shown by ELISA and immune thin layer chromatography on a variety of glycolipids to react specifically are considered serologic responders and additional sera from serological responders may be tested to better define the antibody responεe to vaccination. An additional 60 ml of peripheral blood may be obtained 2 weeks after the fourth vaccination for study of the immune response againεt GM2 at the clonal level if applicantε see evidence of high titer IgG anti-GM2 antibody induction. Supernatants from EBV-transformed lymphoblasts and subsequently produced hybridomas will be used for this purpose. Delayed hypersensitivity response: Skin testε for delayed hypersensitivity against KLH, GM2 and GM2 attached to human serum albumin, will be performed at the time of the fifth immunization. Reactions with more than 5 mm of induration at 48 hours will be considered positive and, if against GM2, will be studied further by skin testε with a variety of gangliosides. Clinical course: Patients will be evaluated at Memorial Hospital at the time of their fourth and sixth vaccinations and a cheεt X-ray and screening profile will be performed at the time of the sixth vaccination. Additional and subsequent follow-up will be performed by their oncologists. Criteria for cessation of treatment Regional recurrence routinely treated by local therapy (surgery or intralesional injection) is no reason for cesεation of treatment if the patient is rendered disease- free. Treatment will be discontinued if the patient developε recurrent diεeaεe requiring εystemic treatment or radiation therapy. Statistical considerations This is a Phase I study primarily concerned with an evaluation of toxicity and the IgG response against GM2 and KLH after vaccination. Three patients will be vaccinated at each QS-21 dose at 4 eεcalating doεes. If the IgG response continues to increase with each escalation: the highest dose producing no more than grade I systemic or grade 2 local toxicity will be selected, and if no toxicity is seen a fifth dose will be tested. Based on εtudieε in the mouse, it is expected that the IgG response to peak or plateau after the second or third dose. Once a safe and immunogenic dose range has been identified, 3-6 additional patients will be immunized at the dose that appears most immunogenic and at the next higher and lower doses to gain confidence in the degree of toxicity and immunogenicity at these doses. Risks GM2-KLH: No toxicity was observed attributed to GM2 over 100 patients treated with vaccines containing 200 ug GM2. KLH has been used at does of lmg to immunize and test the immune status of over 50 patients without toxicity (15) . 18 patients are immunized with vaccines containing GM2-KLH. One patient has experienced pain and tenderness at vaccines sites lasting 48 hours attributable to GM2-KLH, presumably a delayed type hypersensitivity response to KLH. No dose attenuation was required. The only expected side effect of GM2-KLH is inflammation at vaccine sites lasting several days. If fever above 38°C or εevere local toxicity that limitε normal activity occurs, the dose of GM2-KLH in future vaccines may be decreased by a factor of 3. Saponins have not been used in man. They are known to be hemolytic, but the QS-21 fraction was selected because it has shown no clear toxicity at doses as high as 125ug per mouse, cat and Rhesus monkey. On a M 2 or kg basis, this is thousands of times the maximal dose proposed here. Autoimmune or hypersensitivity reactions to components of the vaccine, or to skin teεt antigens, are a theoretical, but remote possibility. Criteria for Toxicity: Toxicity will be graded in accordance with the Common Toxicity Criteria developed by the National C ancer Institute (NCI) . These criteria are on file with the IRB. Significance of study Augmentation of the immune response to cancer can be attempted by two basic approaches-nonspecific immunopotentiation which constitutes the bulk of past and current efforts at cancer immunotherapy, and specific immunization which has not really been evaluated in the treatment of cancer but has contributed much to the control of infectious diseases. It is the knowledge of microbial antigen which has permitted the development of successful specific immunization against infections. The lack of knowledge of human cancer antigens, on the other hand, has prevented exploration of specific immunization in the context of cancer as it should be explored, using vaccines of defined cancer-restricted antigenicity and demonεtrating their immunogenicity in cancer patients. Recent progress in the definition of melanoma cell surface antigens now permits investigation of specific immunization. RESULTS GM2-KLH was used aε antigen in Phase I trial with QS-21. AJCC Stage III and IV melanoma patients who were free of disease after surgical resection of all known disease were immunized with 500 ug of GM2-KLH (GM2/KLH ratio 200-1400/1, GM2 dose 70 ug) plus 10, 50, 100 or 200 ug of QS-21 in groups of 3 patients each. All patients have now received the full 6 immunizations. No toxicity was associated with the 10 or 50 ug QS-21 doses. The 100 ug dose was also well tolerated, but each of the 3 patients treated at this dose had at least 1 of the 6 vaccinations which resulted in a palpable lump and tendernesε for 24-48 hourε and 2 of these patients had thiε occurrence after 2 of the 6 immunizations. No systemic side effects were detected. The 3 patients treated at 200 ug per vaccine experienced tenderness and pain at the injection sites which lasted 2-10 days and low grade fevers and flu-lie symptoms including mild headaches and diffuse aches and pains lasting 8-24 hours after most of the vaccinations. Serologic responses against GM2 and KLH for these 12 patients are summarized at the bottom of Table 2. While the toxicity with the 200 ug dose was not truly the maximum tolerated dose, it was significant toxicity and there was no evidence that it was associated with increased adjuvanticity compared to the 100 ug dose. An additional 9 patients are currently immunized, 3 each at the 50, 100 or 200 ug doses to confirm these toxicity and immunogenicity results. The IgM and IgG titers of the 6 patients receiving GM2-KLH plus 100 or 200 ug QS-21 are shown in Figure 6. It appears that GM2-KLH plus QS-21- (100 ug) is a strikingly immunogenic vaccine, far superior to GM2/BCG or GM2-KLH plus DETOX or BCG with regard to both the titers and the duration of IgM and IgG antibodies. Having shown that the GM2-KLH and GD3-KLH plus QS-21 vaccines are significantly more immunogenic that the previous ganglioside/BCG vaccines, the immunogenicity of GD2, GD3, and GD3 lactone in these new conjugate vaccines will be tested in the clinic. The basis for selecting these gangliosideε aε immunogenε in melanoma iε a quantitative analysis of twenty melanoma biopsies using immune thin layer chromatography to quantitate the levels of these gangliosideε on melanomaε and variouε normal tissueε. Six to twelve melanoma patientε will be vaccinated with each of these ganglioside conjugateε which have been prepared and covalently attached to KLH. Conjugateε which are shown to be immunogenic in these pilot studies will then be pooled and tested in an additional group of 12 patients as a prelude to a large multi-center trial aimed at determining the impact of a consistently immunogenic polyvalent melanoma ganglioside vaccine on recurrence rate and survival. TABLE 2 PEAK ANTIBODY TITER AGAINST GANGLIOSIDE GM2 AFTER IMMUNIZATION WITH GM2-KLH PLUS VARIOUS IMMUNOLOGICAL ADJUVANTS Antibody Titers Dot Blot Immune bv Elisa Stain Vaccine Number IgM IgG IgM IgG of Patients GM2/BCG 640(2) , 40,0(5) 3 + (4) , l + (3) ,0 160(3) ,0 2 + ,0 (3) GM2-KLH 160(2) ,80 0(6) 3 + (2) , l + (2) ,0 (2) ,40,0 2 + (2) ,0 (4) (2) GM2-KLH 320,160 160,0 3 + (2) , 2 + ,0(5) +Detox (4) ,0 (5) 2 + (3) , 1 + GM2-KLH 1280,320 320,20 3\2 + l + (2) ,0 +BCG (2) ,80 (2) ,0 (3) ,0 (4) (2) ,0 (3) (2) GM2-KLH 5120(2) , 1280 3 + (5) , 3 + (5) , +QS-21 1280(3) , (2) ,640 2 + 2 + 320 ,320 160,80 10 ug 3 1280, 160,80, 3 + (2) , 3 + (2) , 640, 40 0 2 + 2 + 50 ug 3 640,320, 80(2) , 3\2 + 3 + ,2 + (2) 160 40 (2) 100 ug 3 5120,1280 1280, 3 + (3) 3 + (3) (2) 640,160 200 ug 3 5120, 1280, 3 + (3) 3 + (2), 1280,320 320,80 2+ Third Series of κ*pariments The cell surface gangliosides GM2, GD2 and GD3 are often overexpressed in malignant melanoma. Applicants have shown previously that immunization of melanoma patients with GM2 and BCG induced an IgM antibody response in most patients, and that patients with high titer GM2 antibodies showed increased survival. As is commonly seen with carbohydrate antigens (which are T-independent) , the IgM response was short-lived, and an IgG response was rarely observed. To increase immunogenicity, applicants conjugated GM2 covalently with keyhole limpet hemocyanin (KLH) . GM2-KLH vaccine was given to melanoma patients with one of three adjuvants - BCG, DETOX or QS-21. The most effective vaccine was GM2-KLH with QS-21. It induced a much higher titer and longer lasting IgM GM2 antibody response, and a consistent IgG response (isotype IgGl and IgG3) . It also induced the highest titer anti KLH response The results suggest that the conjugate GM2-KLH plus QS-21 vaccine elicited εignificant T cell help. Aε there waε no serious toxicity, this vaccine approach is attractive for augmenting the immunogenicity of other gangliosideε such as GD2 and GD3 and for determine the effectε of ganglioside antibodies on the course of melanoma. In addition, the finding that QS-21 significantly increased the immunogenicity of GM2-KLH suggests that it may do the same for other conjugate vaccines, many of which are currently used without adjuvant. Introduction One of the changes that occur in the proceεε of malignant transformation iε an altered pattern of cell surface ganglioside expreεsion in certain types of cancer, including malignant melanoma (1) . In normal melanocytes, GM33 is the predominant ganglioside. Other gangliosides which include GD3, GM2, GDla and GTlb, constitute less than 10% of the total (2) . In, malignant melanoma, activation of glycosylating enzymes leads to increased expression of GD3, GD2, GM2 and 9-0-acetyl GD3 (3,4). These overexpressed gangliosides are attractive targets for immunotherapy, including active immunization with ganglioside vaccines. In a series of studies involving GM2 vaccines in patients with malignant melanoma, applicants have shown that vaccination (after low-dose cyclophosphamide and with BCG as adjuvant) induces IgM antibodies to GM2 in most patients (5) , and that disease-free interval and survival are extended in patients producing high-titer GM2 antibodies (6,7). However, the induced antibody reεponεe to GM2 has the characteristics of a T-independent response (predominantly IgM, short duration, inconsiεtent IgG response, lack of booster effect) , and the other melanoma gangliosides, GD3 and GD2, are not immunogenic when administered in the εame way (8) . Aε the relevant epitopes are carbohydrates, applicants have explored approaches to increasing immunogenicity that are suggested by the εuccessful development of carbohydrate vaccineε for bacterial infections. In the mouse, applicants have shown that the immunogenicity of GD3 is markedly increased by covalent binding to keyhole limpet hemocyanin, and that mice immunized with the GD3-KLH conjugate and the adjuvant QS-21 εhow a high-titer IgM reεponse followed by a strong, long-lasting IgG responεe (9) . Applicants have now begun to teεt ganglioεide conjugate vaccineε in the clinic, and applicantε report here the initial resultε of immunizing patientε with malignant melanoma with a GM2-KLH conjugate vaccine. Materials and Methods Patients Patients with malignant melanoma Stage III were considered eligible if all metastatic disease had been rejected within the last 4 months. None of the patients had received prior chemotherapy or radiation therapy. Vaccine Preparation and Adminiεtration GM2-KLH vaccine: GM2-KLH conjugate waε prepared by Biomira Inc. (Edmonton, Alberta) as described previously for GD3-KLH conjugate vaccine (9) . Briefly, the conjugation procedure involved ozone cleavage of the ceramide double bond of GM2, introduction of an aldehyde group, and conjugation to aminolysyl groupε of KLH by reductive amination. The GM2/KLH molar ratio was approximately 800/1, and the vaccine was supplied at a concentration of 0.57mg conjugate in 0.5 ml normal saline. This amount represented one patient dose and contained 70μg GM2 and 500μg KLH. Groups of six patients each received GM2-KLH conjugate without adjuvant, GM2-KLH with DETOX, GM2-KLH with BCG and GM2-KLH with QS-21. Four vaccinations were administered intradermally into extremities with intact lymphatic drainage at two-week intervals, followed by two additional vaccinations at eight week intervals. Cyclophosphamide (Cytoxan, Mead Johnson and Co., Evansville, IN) 200mg/m2 was administered intravenously to all patients 4 to 6 days prior to the first vaccination. Immunological adjuvants: DETOX was produced and supplied by Ribi Immunochem Research Inc. (Hamilton, MT) , formulated as a lyophilized oil droplet emulεion. It consistε of cell wall εkeletonε (CWS) from bacille Calmette-Guorin and monophoεphoryl lipid A (MPLA) from Salmonella minnesota R595. On the day of vaccination, 0.25 ml DETOX (250μg CWS and 25μg MPLA) waε mixed with the GM2-KLH preparation. The vaccine (final volume 0.75ml) waε vortexed for 2-3 minutes and administered to the patients within 15 min. BCG was purchased from Bionetics Research Inc. (Rockville, MD) . On the day of vaccination, 107 viable units of BCG in 0.1 ml normal saline were added to the GM2-KLH vaccine in each individual syringe (final volume 0.6 ml) . The contents were mixed and administered to the patients within 15 min. QS-21 adjuvant (a homogeneous saponin purified from the bark of Quillaja saponaria Molina) (10,11) was kindly provided by Cambridge Biotech Inc. (Worcester, MA) . lOOμg or 200μg of QS-21 were diluted in 0.25ml normal εaline and mixed with GM2-KLH. The vaccine (final volume 0.75ml) waε vortexed for 2-3 minuteε and administered within 15 min. Gangliosides GM2 and GDlb from bovine brain were a gift from Fidia Research Laboratory (Abano Terme, Italy) . GM3, GM1 and GDla from bovine brain were purchased from Sigma Chemical Co. (St. Louis, MO) . Asialo-GM2 waε prepared by treatment of GM2 with 0.1M trifluoroacetic acid at 100°C for lh followed by separation on a Sep-Pak C18 reversed-phase column (Waters, Milford, MA) . GD2 was made from GDlb by treatment with β-galactosidaεe (12) . GD3 iεolated from bovine buttermilk waε kindly provided by Dr. R. K. Yu (Medical College of Virginia, Richmond, VA) . Reagents and monoclonal antibodies High-performance thin-layer chromatography (HPTLC) silica gel plates were obtained from E. Merck (Darmεtadt, Germany) . 4-chloro-l-naphthol and p-nitrophenyl phosphate disodium were obtained from Sigma. Alkaline phosphatase-conjugated goat anti-human IgM (Kierkegaard and Perry Labs, Gaithersburg, MD) and mouse anti-human IgG-purified (Southern Biotech, Birmingham, AL) followed by alkaline phosphatase-conjugated goat anti-mouse IgG (Southern Biotech) were used for enzyme-linked immunosorbent assays (ELISA) . Horseradish peroxidase-conjugated goat anti-human IgM or IgG purchased from TAGO (Burlingame, CA) were used for dot blot immune stain and immune thin layer chromatography (ITLC) . Rabbit anti-mouse immunoglobulin conjugated to horseradish peroxidase for ITLC, and rabbit anti-mouse IgM and IgG conjugated to alkaline phosphatase for ELISA were used with control monoclonal mouse antibodies, and were obtained from Zymed (San Francisco, CA) . Anti-GM2 mAb 696 was obtained from Kyowa Hakko Kogyo (Tokyo, Japan) and anti-GD3 mAb R24 was generated (13). Serological aεεayε ELISA waε performed aε previouεly deεcribed (6) . To control for nonspecific "stickiness", immune sera were also tested on plates which were processed identically but to which no ganglioside had been added, and the reading waε εubtracted from the value obtained in the presence of ganglioεide. The titer was defined as the higheεt dilution yielding a corrected abεorbance of 0.1 or greater. Immunostaining of gangliosides with monoclonal antibodies or human εera was performed after spotting on nitrocellulose strips (14) or separation on HPTLC silica gel glaεs plates aε previouεly deεcribed (3) . Plateε were developed in chloroform/methanol/water (0.25% CaCl2) 50:40:10 (v/v), and ganglioεideε were visualized by staining with resorcinol/HCl reagent or monoclonal antibodieε. Determination of IgG εubclaεε Determination of IgG εubclaεε waε performed by ELISA using subclasε-εpecific εecondary mouεe anti-human IgGl, IgG2, IgG3, and IgG4 mAbε. Secondary mAbε from different suppliers (Table 4) were used. Alkaline phosphatase conjugated to goat anti-mouse IgG (Southern Biotech, Birmingham, AL) waε used aε third antibody at a dilution of 1:200. Complement-mediated cytotoxicitv assays Complement-mediated cytotoxicity assays were performed by a 4h 51Cr release asεay. Cellε from the GM2-poεitive melanoma cell line SK-MEL-173 served as target cells. 2x106 cells were labelled with lOOμCi Na251Cr04 (New England Nuclear, Boston, MA) in 10% FCS RPMI for lh at 37°C in a C02 incubator. The cells were washed twice, and 104 cells/well in 96-well round-bottom plates (Corning, New York, NY) were labelled and incubated with 1:5 diluted pre- or post-vaccination serum or with medium alone for lh at 37°C in a C02 incubator. The cellε were washed and incubated with human complement (Sigma) at a dilution of 1:4 for 4h at 37oC. The plates were spun at- 500g for 5 min, and an aliquot of 125μl of supernatant of each well was harvested for determination of released 51Cr. All asεays were performed in triplicate and included control wells for maximum releaεe in 1% NP-40 (Sigma) and for εpontaneous release in the absence of complement. The percentage of specific lysiε was calculated aε follows: Experimental release - spontaneous release % cytotoxicity = x 100 Maximum release - spontaneous release RESULTS Vaccine administration and side effects Twenty four patients were immunized with the GM2-KLH vaccine. Groups of six patients each received GM2-KLH with no immunological adjuvant or with DETOX, BCG or QS-21. No local or syεtemic toxicity waε detected after administration of GM2-KLH alone. Vaccines containing DETOX resulted in nodule formation at vaccination siteε in four of six patients which lasted 2-10 weeks. In four patients these were associated with 3-10 cm of erythema and induration but only minimal tenderness. In one patient it was associated with 25 cm erythema and induration after one immunization and in a second patient low grade fever and malaise for 72 hours after the first immunization. In this patient the DETOX dose was reduced to 50μg CWS and 5μg MPLA for subsequent immunizations. BCG produced local inflammation and crusting at some point in all patients which healed after 2-12 weeks. When this occurred, the dose of BCG was reduced from 1x107 viable units to a final dose of 3x106 units in four patients and 1x106 unitε in one patient. The sixth patient had a history of tuberculosis exposure and a positive PPD test. He was therefore started at a dose of 1x106 units which was eventually reduced to 1x105 units. QS-21 induced mild local erythema and tenderness lasting 24-48 hours in all patients at the lOOμg dose. The 200μg dose of QS-21 was aεεociated with local tenderness and inflammation lasting 2-10 days after all immunizations as well as mild flu-like εymptomε including low grade fever (<38.5oC), headache and myalgia laεting 8-24 hourε after 3 of the 18 immunizations. No neurological abnormalities or other side effects were observed. Antibody response to GM2-KLH conjugate vaccines Prior to vaccination, IgG antibodies against GM2 were not found, and IgM antibodieε were detected only in three patients, with titers of 1:80 in two 1:320 in one. The remaining 21 patients showed no GM2 reactivity before vaccination. ELISA and dot blot immune stain results with sera obtained before and after immunization are summarized in Table 3. IgM antibody titers after immunization with GM2-KLH, or with GM2-KLH and BCG or GM2-KLH and DETOX, were quite similar (median titer 1:80 - 1:160). In contrast, 5 of 6 patients immunizated with GM2-KLH and QS-21 showed IgM antibody titers of 1:1280 or more, significantly higher than the titers in the other groups or in patientε previously immunized with unconjugated GM2 and BCG vaccines (6) . In addition, immunization with GM2-KLH and QS-21 induced a consistent IgG response for the first time in all patients; only 2 of the other 18 patients receiving GM2-KLH vaccines produced comparable IgG titers. Sequential IgM and IgG antibody titerε againεt GM2 in patientε receiving GM2-KLH and QS-21 are shown in Figure 6. IgM peak titers were seen after the third or fourth vaccination and remained high in moεt patientε for at leaεt 20 weekε. Booster immunizations at week 14 and 22 did not further increase IgM titers. IgG titers of 1:160 or higher were seen two weeks after the fourth vaccination in five of six patientε. The titers decreased to 1:40 or leεε but rapidly increased again after booster vaccination to the previous levels (median 1:160) and remained at this level for more than 11 weeks. The second booster vaccination had no clear effect on antibody titers in most cases. Thus, the reεponse to booster vaccination εhowed only one of two characteriεtics of the classical secondary immune response. The response occurred more rapidly, but antibody titers did not riεe higher than after the initial immunizationε. KLH antibodieε were not detected in pretreatment sera. After vaccination all patientε εera showed reactivity with KLH as indicated in Table 3. The highest titers of IgG antibodieε were seen after administration with QS-21, significantly higher than in all other groups, including the next-best group of patients vaccinated with GM2-KLH and BCG (p<0.005). In the QS-21 group, there was no correlation between the strength of the GM2 response and the KLH response. Specificity analvsiε of GM2 antibodieε The specificity of ganglioside antibodies detected in the patients' sera before and after immunization was determined by dot blot immune stain utilizing the ganglioside standards GM3, asialo-GM2, GM2, GM1, GD2, GD3, GDla and GDlb (Figure 7) . Preimmunization IgM and IgG antibodies from most patients showed weak reactivity with asialo-GM2, and some patients also had IgM antibodies against GM1 and GDlb. Reactivity with these gangliosides was not altered by immunization. The only vaccine-induced changes were strong reactivity with GM2 and weak reactivity with GD2. Dot blot immune stains were graded aε 0, 1+, 2+, or 3+. 3+ reactivity of IgM antibodies against GM2 was seen in the serum of five of six patients immunized with GM2-KLH and QS-21, in one of six patients treated with GM2-KLH and BCG, and in two of six patientε treated with GM2-KLH without adjuvant or GM2-KLH and DETOX. 3+ reactivity of IgG antibodieε waε seen in five of six patientε immunized with GM2-KLH and QS-21 and in none of the patientε in the other treatment groupε. Postvaccination sera from patients immunized with GM2-KLH and QS-21 were also tested by immune thin layer chromatography (Figure 8A) for reactivity with GM2 and other gangliosides of a melanoma tissue extract. Most patients' sera showed strong IgG and IgM reactivity with GM2 isolated from bovine brain or melanoma. Reactivity was seen also with a slower migrating band in the melanoma extract, presumably GD2 when comparing the Rf value with a purified GD2 standard (not shown) . To confirm the GD2 crossreactivity of IgG antibodies, postvaccination serum from patient No. 2 was preincubated with either GM2 or GD2 before performing the immune stain (Figure 8B) . Reactivity with GM2, and with GD2 in the melanoma ganglioside extract, was completely inhibited by preincubation with GM2. On the other hand, preincubation of the same serum with GD2 resulted in inhibition of GD2 reactivity only, and did not change reactivity with GM2. These results suggest the presence of two populations of antibodies, one reacting with GM2 alone and another with reactivity for GM2 and GD2. Subclass determination of IgG antibodies High titer IgG sera from the εix patientε immunized with GM2-KLH and QS-21 were tested by ELISA using a panel of IgG-subclass specific secondary antibodies. The results are summarized in Table 4. The IgG antibodies in all six sera were of IgGl and IgG3 subclasε. Complement-mediated cytotoxicity Effector function of anti GM2 antibodieε in the εerum of patientε vaccinated with GM2-KLH and QS-21 (diluted 1:5) was tested by complement-mediated cytotoxicity asεays. As shown in Table 5, poεt-vaccination εera of all εix patients lysed GM2-positive SK-MEL-173 melanoma cells in the presence of human complement. Prevaccination sera showed no cytotoxicity with addition of complement, and postvaccination sera were not cytotoxic with GM2 negative melanoma cells or when complement waε not added. Clearly, theεe are only preliminary reεultε, and more detailed study of cell surface binding and cytotoxic effector functions of vaccine-induced antibodies and their subclasseε iε now underway. Discussion In a series of studies in patients with malignant melanoma, the objective has been to construct vaccines that are effective in inducing production of antibodies against three gangliosides often overexpressed in melanoma - GM2, GD2 and GD3. The initial approach was to vaccinate patients with unconjugated gangliosides adsorbed to BCG. In this way we were able to induce antibody production against GM2 (5,6) but not GD2 or GD3. GM2 antibodies induced by GM2-BCG vaccines were mostly of the IgM class, the antibody response was of short duration, and booster immunization resulted again in a brief period of IgM antibody production similar to the primary responεe - all characteristics of a T-cell independent immune response, well known from studies of other carbohydrate antigens. Even εo, vaccine-induced production of GM2 antibodies by patientε with Stage III melanoma after surgery was associated with increased survival (6,7). This observation εuggested that melanoma gangliosideε are appropriate candidates for vaccine construction, and that melanoma ganglioside vaccines of increased immunogenicity might result in superior clinical outcomes. As the relevant epitopes of melanoma gangliosides are carbohydrates it is helpful to consider studies that have been aimed at increasing the immunogenicity of other carbohydrate vaccines, notably vaccines against certain bacterial infections. The major distinction of the immune response to carbohydrate antigens, as opposed to protein antigens, is that it does not depend on the thymus. The concept that carbohydrate antigens are thymus-independent (TI) is based on the observation that neonatally thymectomized mice as well aε thymic mice show unimpaired humoral immune responses to bacterial polysaccharides (15) . B-cells that respond to TI antigens show several characteristic features. They appear later in ontogeny, are long-lived, and do not require T-cells for activation, at least not in vivo. Although T-cells are required for B-cellε to respond to TI antigens in vitro, the nature of the T-cell effect iε poorly understood and clearly different from the MHC-restricted T-cell help in the T-dependent antibody response to protein antigens. While T-cells are not indispensable for the in vivo antibody response to TI antigens, antibody levelε are higher when T-cellε are present, suggesting a general augmenting activity of T-cells, again by unknown mechanisms (16). A large variety of approaches has been explored in attempts to increase the immunogenicity of carbohydrate antigens. They include chemical modification (17) , administration with adjuvants, non-covalent complexing with proteinε, covalent attachment to immunogenic protein carriers (18) , and replacement of the carbohydrate epitope by a protein replica, either peptides synthesized de novo (so-called mimotopes, 19) or anti-idiotypic antibodies (20) . Most of these approaches result in increaεed T cell help for the carbohydrate εpecific antibody reεponεe. While each has shown promise in initial experimentation, covalent attachment of carbohydrate antigens to immunogenic T-dependent protein carriers, as first suggested for haptens (21) and then disaccharides (22) , is the concept that has been pursued most vigorously, resulting in vaccines that have in some instanceε been εhown to be highly effective in recent clinical trialε. Excellent exampleε are H. influenzae type b (Hib) polyεaccharide protein conjugate vaccines. Four vaccines that have been developed over the last decade differ in the carbohydrate components, protein carriers and linkers between carbohydrate and protein (23-27) . In comparative studies in children, conjugate vaccines induced a much stronger antibody response than unconjugated Hib phosphoribosyl/ribitolphosphatepolysaccharide (PRP) vaccine (28) . Of particular interest are observations that young children first immunized with HbOC (oligosaccharide-nontoxic diphtheria toxin) or PRP-OMPC (outer membrane protein complex of Neisseria meningitidis type B) vaccines and later challenged with unconjugated PRP vaccine showed an anamnestic IgG response even if challenged at an age at which they do not respond to primary immunization with the unconjugated vaccine (29,30). How T-cells are engaged, and how they interact with Hib PRP-responsive B-cells, is still far from clear. The fact that increased immunogenicity and T-dependence require a covalent bond between PRP and protein εuggeεts that the proximity between protein and PRP must not be disturbed, at least not in the early phase of antigen procesεing. As the isotype and biological activities of antibodies induced by Hib PRP and Hib PRP conjugateε are the same, it appears that the B-cells that respond to the conjugate-induced T-cell signal are qualitatively identical with those engaged by Hib PRP alone. Drawing on the subεtantial experience that has accumulated in the development of carbohydrate vaccines for bacterial infections, applicants have explored, over the past several years, εimilar approaches in attempts to increaεe the immunogenicity of melanoma gangliosides. Chemical modification of GD3, resulting in amide, lactone or gangliosidol formation, or O-acetylation, produced derivatives that were highly effective in inducing antibody production in patients with melanoma. However, the antibodies induced by these GD3 derivativeε did not cross-react with GD3 (31,32). An anti-idiotypic antibody BEC-2, mimicking GD3, has been developed by immunizing mice with the monoclonal antibody R24 which recognizes GD3. Rabbits immunized with BEC-2 produced anti-GD3 antibodies (33), and initial studies of the immunogenicity of BEC-2 in human patients are underway. Regarding conjugate vaccines, initial studies with GD3 in the mouse were concerned with three issues - development of the conjugation method, selection of the carrier protein, and choice of the adjuvant (7) . The optimal conjugation procedure involved ozone cleavage of the double bond of GD3 in the ceramide backbone, introduction of an aldehyde group, and coupling to protein aminolysyl groups by reductive amination. Of five carriers tested - poly-1-lysine, keyhole limpet hemocyanin (KLH) , cationized bovine serum albumin, Neisseria meningitidis outer membrane protein complex (OMPC) , and multiple antigenic peptide constructs containing four repeats of a malarial T-cell epitope on a branching polylysine core -, KLH waε found to be most effective. Noncovalent GD3/KLH complexes were not immunogenic. The best adjuvant waε QS-21, a homogeneous saponin fraction purified from the bark of Quillaja saponaria Molina. The characteristics of the antibody responεe to immunization with GD3-KLH conjugate and QS-21 included a) a high initial IgM antibody titer, b) a rapid εecondary riεe of IgM antibody titers after booster immunizationε, c) maintenance of IgM antibody titerε after booster immunization for up to ten weeks, and d) consistent production of IgG antibodies at high titers, parallel to IgM antibody production except for the initial delay of two weeks. These findings have now been reproduced in human melanoma patients by immunization with another ganglioside conjugate vaccine, GM2-KLH, using the same conjugation procedure. As in the mouse studies, QS-21 proved to be a significantly more effective adjuvant than DETOX or BCG, with acceptable toxicity. The GM2 antibody response had many characteristics of a T cell dependent response. It was long-lasting, and antibodies of IgGl and IgG3 subclass (usually associated with a T cell dependent immune response) were induced. As seen with the Hib-PRP vaccines, these isotypes were the same as those induced occasionally at low titers with unconjugated GM2/BCG vaccineε. The lack of a clear booster effect in the sustained high-titer IgM and IgG response after vaccinations three and five months following the initial series may be explained by the fact that the patients were immunized at two-week intervals initially. In the classical experiment showing the secondary response to protein antigens, the second injection of antigen is given four weeks after the firεt. Antibody levelε after the first immunization are higher between one and two weeks after the injection, and then decline to very low levelε before the booεter injection iε given after four weekε. In the immunization εchedule applicants chose, the initial antibody response did not subεide but increaεed in a εtepwise fashion in response to the first four vaccinations at two-week intervals, anticipating the secondary responεe that iε seen in a more dramatic fashion in the classical experiment. Unlike the antibody response to most protein antigens, the IgM response was long-lasting, and IgM antibodies remained at higher titer than IgG antibodies, even after repeated booster immunizations, as is characteristic for carbohydrate antigens. Hence the immune reεponεe against ganglioεides which contain a comparably short oligosaccharide chain linked to a lipid backbone and which are autoantigens show much in common with the immune response against Hib-PRP and other bacterial carbohydrates. The development of the GM2-conjugate vaccine will make it possible to determine whether higher levels of IgM and IgG antibodies against GM2, sustained over longer periods, will be more effective in delaying recurrence of melanoma than the lower levels of mostly IgM antibodies, present for shorter periods, in patients immunized with unconjugated GM2. In addition, applicants can now test whether conjugation with immunogenic protein carriers alεo conferε immunogenicity to GD3 and GD2, major gangliosides which have not induced an antibody response in melanoma patients when given as unconjugated vaccines. If this can be accomplished, construction and testing of a polyvalent melanoma ganglioside vaccine would be an attractive next εtep. Table 3 Serological response of patients receiving GM2-KLH conjugate vaccines with or without adjuvants in comparison to vaccine containing GM2 adherent to BCG (GM2/BCG) Reciprocal GM2 antibody titers Vaccine No. of before immunization after immunization Patients (Peak^ IgM IgG IgM IgG GM2-KLH 6 20,0(5) 0(6) 160(2) ,80 160,0(5) (2) ,40,0 median 0 0 80 0 titers: GM2-KLH 6 20(2) ,0 0(6) 320,160 160,0(5) + DETOX (4) (4),0 median 10 0 160 0 titers: GM2-KLH 6 80(2) ,20 0(6) 1280,320 320,20 + BCG (2) , 0(2) (2) ,80 (2),0(3) (2) ,0 median 20 0 200 10 titers: GM2-KLH 6 320,20 0(6) 5120(2) , 1280,640 + QS-21 (2) ,0(3) 1280(3) , (2) ,320, 320 160,80 median 10 0 1280 480 titers: GM2/BCG 8 58 160,40,20 0(58) 640(11) , 640,160, (10) ,10 320(9) , 80(4) , (11), 160(15) , 20, 0(35) 80(8) , 10(3), 40(8), 0(48) 20(2) , 10(3) , 0(2) median 0 0 160 0 titers: 'historical data(6) Table 3 (continued) Table 4: Characterization by IgG-subclaεε Specific MoAbε of IgG Abs induced against GM2 induced with GM2-KLH plus QS-21 vaccine IgG subclass mABS Reciprocal ELISA Titer against GM2 Patient No. Specificity cone, Abs (ug/ul) εource 1 2 3 4 5 6 IgG 10 SBA" 640 640 640 640 640 64 20 BS 40 20 20 nd 20 2 5 ZLI 640 640 640 640 640 64 IgGl 10 SBA 10 10 10 10 10 1 20 BS 10 10 0 10 0 2 ZLI 10 0 10 0 10 0 IgG2 10 SBA 10 0 0 0 0 0 20 BS 0 0 0 0 0 0 2 ZLI 0 0 0 0 0 0 IgG3 10 SBA 20 20 20 20 20 20 20 BS 40 80 40 40 40 40 2 ZLI 20 40 20 10 10 20 IgG4 10 SBA 0 0 0 0 0 0 20 BS 0 0 0 0 0 0 2 ZLI 0 0 0 0 0 o "SBA, Southern Biotechnclogy Aεstociates (Bijrmingham, AL) ; BS / The Binding Site Ltd.; ZLI, Zymed Laboratories Inc. (San Francisco, CA) Table 5 Complement lysis of melanoma cell line SK-MEL-178 mediated by GM2 antibodies in sera from patients immunized with GM2-KLH plus QS-21 Percentage of lysiε* Patient Pre Post Post No. vaccination vaccination vaccination serum with serum with serum without complement complement complement 1 1.3 38.75 3.1 2 2.2 16.9 2.72 3 1.1 14.0 0.9 4 1.2 26.0 2.2 5 2.1 34.9 1.65 6 10.5 44.7 2.3 "Target cells were labeled with 51 Cr and treated with 1:5 diluted anti sera. Fourth Series of Experiments Increasing doseε of saponin fraction QS-21 were administered as immunological adjuvant in a Phase I trial with a constant dose of the melanoma ganglioside GM2 covalently attached to keyhole limpet hemocyanin (KLH) . Twenty-eight patients with AJCC Stage III or IV melanoma who were free of disease after surgery were treated with six vaccinations administered subcutaneously over a 5 month period. Local and systemic reactions were QS-21 dose related. Doses of 100 ug or lesε induced mild local tendernesε and inflammation at vaccination sites lasting 2-4 days and occasional brief low grade fever and malaise, but no significant incapacitation. The 200 ug dose induced low grade fever and malaise after 30% of vaccinations and local reactions as large as 20 cm in diameter were seen in all patients resulting in restricted usage of the injected extremity for 5-10 days. The titers of IgM and IgG antibodieε against GM2, and IgG antibodies against KLH, were highest at the 100 and 200 ug QS-21 doses. No antibodies against QS-21 were detected. This trial identifieε the 100 ug dose of QS-21 as the optimal well tolerated dose for induction of antibodies against GM2 and KLH in melanoma patients. INTRODUCTION Applicants and otherε have vaccinated melanoma patients with a serieε of whole melanoma cell vaccines selected for expreεεion of a variety of glycoprotein and ganglioεide antigenε (1,2). The antigen recognized most frequently by antibodies in poεt vaccination sera was the ganglioside GM2. GM2 ganglioside is a differentiation antigen overexpressed on the cell surface of human malignant melanomas. GM2 injected alone was found not to be immunogenic and so GM2 vaccines containing a variety of immunological adjuvants were tested (3,4). Immunization with purified GM2 ganglioside adherent to Bacillus Calmette-Guέrin (BCG) induced production of IgM antibody against GM2 in most melanoma patients and patients producing antibody had a longer disease-free interval and survival when compared to patients who did not produce antibody (4,5). In a randomized study with 122 melanoma patients who were disease free after surgery, the majority of patients (86%) receiving the GM2/BCG vaccine produced antibodies (6) . Patients that produced anti-GM2 antibodies had a εignificantly longer disease free interval and overall survival than antibody negative patientε. Comparing the two arms of the trial, patients receiving, the GM2/BCG vaccine had an 18% improvement in disease free interval and an 11% improvement in survival when compared to the BCG control group, though neither difference was statistically significant. The immune responεe waε of εhort duration, moεtly IgM and of moderate titer. Similar approaches with other melanoma gangliosideε GD2, GD3 and 9-0-acetyl GD3/BCG vaccines in patients resulted in only occasional low titer antibody responseε (7) . The need for a more effective vaccine was evident. Landsteiner's claεεical experimentε with hapten carrier conjugates had been succeεεfully applied to vaccination againεt a variety of antigens including bacterial capεular polyεaccharideε in infants (8) . Based on this background, several different carbohydrate tumor antigens were conjugated to keyhole limpet hemocyanin (KLH) , and shown to elicit higher titer IgM and IgG antibody responses than previously seen with nonconjugate vaccineε (9-11) . Applicantε teεted the immunogenicity of GD3 linked to a variety of carrier moleculeε in the mouse and identified KLH as the optimal carrier (12) . A GM2- KLH conjugate vaccine waε tested alone or mixed with immunological adjuvants BCG and DETOX in melanoma patients but the immune response was not significantly different than that induced by GM2-BCG vaccines, moderate titer IgM antibodies alone were induced (13) . A more potent immunological adjuvant was required. QS-21 is a saponin fraction purified to near homogeneity from Quillaja saponaria Molina bark and selected for high adjuvant effect and low toxicity (14,15). Saponins have been used as immunological adjuvants in a variety of settings (reviewed in 15) . QS-21 has been used to augment the antibody response against an E. coli polysaccharide (16) , and the antibody and T cell responses against an HIV-1 envelope protein (17) , ovalbumin (18) , and feline leukemia virus (19) . Cytotoxic T cells have been induced against HIV infected cellε and ovalbumin transfected cells by immunization with protein/QS-21 mixtures (17,18). Applicants tested a variety of new immunological adjuvants with various carbohydrate antigen-KLH conjugate vaccines and the immunological adjuvantε QS-21 and SAF m were found to most effectively augment IgM and IgG antibody titers (9) . Experiments focused on QS-21 since it waε the leaεt toxic and waε available for teεting with conjugate vaccineε. GD3 ganglioside-KLH plus QS-21 vaccineε in the mouse induced consistent high titer IgM and IgG antibody responses (12) , providing the baεiε for teεting thiε approach in melanoma patients. Deεcribed herein are the resultε of a Phaεe I trial uεing a conεtant doεe of GM2-KLH pluε increaεing doεeε of QS- 21. Since purified QS-21 or partially purified εaponinε such as Quil A had not previously been used in humans, the goal was to determine the maximum tolerated dose consistent with repeated outpatient administration and the optimal dose for augmenting the antibody response to GM2. Materials and Methods Gangliosideε GM2 and GDlb from bovine brain, were a gift from Fidia Reεearch Laboratory (Abano Terme, Italy). GM3, GMi and GDla from bovine brain were purchaεed from Sigma Chemical Co. (St. Louiε, MO) . GD2 waε made from GDlb by treatment with /3-galactosidase (20) . GD3 waε iεolated from bovine buttermilk and kindly provided by Dr. R.K. Yu (Medical College of Virginia, Richmond, VA) . Reagentε and monoclonal antibodieε HPTLC silica gel plates were obtained from E. Merck (Darmstadt, Germany) ; 4-chloro-l-naphthol, p-nitrophenyl phosphate disodium from Sigma. Alkaline phosphatase- conjugated goat anti-human IgM (Kierkegaard and Perry Labs, Gaithersburg, MD) and mouse anti-human IgG-purified (Southern Biotech, Birmingham, AL) followed by alkaline phosphatase-conjugated goat anti-mouse IgG (Southern Biotech) were uεed for ELISA. Horseradish peroxidase- conjugated goat anti-human IgM or IgG purchased from TAGO (Burlingame, CA) were used for dot blot immune stain and immune thin layer chromatography. Rabbit anti-mouse immunoglobulins conjugated to horseradish peroxidase for ITLC, and rabbit anti-mouse IgM and IgG conjugated to alkaline phoεphataεe for ELISA were used with control monoclonal antibodies, and were obtained from Zymed (San Francisco, CA) . Anti-GM2 mAb 696 was obtained from Kyowa Hakko Kogyo (Tokyo, Japan) and anti-GD3 mAb R24 waε generated (21) . Patients Melanoma patients with AJCC Stage III or IV disease were considered eligible if all evidence of metastatic disease had been rejected within the last 8 months. None of the patients had received prior chemotherapy or radiation therapy. Patients were evaluated for toxicity at the time of each vaccination. In addition, patients were instructed to measure local reactions and to take their temperature. These results were called in and then reviewed at the next clinic visit. Four patients (one at each of the 4 dose levels) received only 4 immunizations due to disease progression necessitating other treatment. Vaccine Preparation and Adminiεtration GM2-KLH conjugate was prepared by Biomira Inc. (Edmonton, Alberta) . The GM2/KLH molar ratio was approximately 800/1 and was supplied at a concentration of 0.57 mg conjugate per 0.5 ml normal saline. This represented one patient dose and contained 70 ug GM2, 500 ug KLH and 0.5 ml normal saline. QS-21 adjuvant, containing a saponin component isolated from Quillaja εaponaria Molina tree bark, was provided by Cambridge Biotech Corp. (Worcester, MA) . The purity of the QS-21 was determined to be >98% by analytical reverse phaεe HPLC. Ten, 50, 100 or 200 ug of QS-21 were diluted in 0.25 ml normal saline and mixed with GM2-KLH. The vaccine (final volume 0.75 ml) waε vortexed for 2-3 minuteε and administered within 15 min. Four vaccinations were administered subcutaneously at two week intervals followed by two more at eight week intervals. Initially 12 patients were treated, 3 at each of the 4 QS-21 doses. Subsequently 1 additional patient was treated at the 10 ug dose and 3 additional patients were treated at the 3 higher doses. Cyclophosphamide (Cytoxan, Mead Johnson and Co., Evansville, IN) 200 mg/M 2 was administered IV to all patients 3-6 days prior to the first vaccination. Serological and delaved-tvpe hypersensitivity (DTH) assays Enzyme-linked Immunosorbent Assays (ELISA) were performed as previously described for gangliosideε (5) . For ELISA assays on QS-21, QS-21:ethylenediamine (prepared by linkage of ethylene diamine to the QS-21 glucuronic acid carboxyl group) was plated on glutaraldehyde treated Immulon 4 plates (Dynatech Labs, Chantilly, VA) . To control nonspecific "stickiness", immune sera were also tested on plates which were proceεεed identically but to which no ganglioεide KLH or QS-21 had been added, and the reading was subtracted from the value obtained in the presence of antigen. The titer was defined as the higheεt dilution yielding a corrected abεorbance of 0.1 or greater. Immunostaining of gangliosides with monoclonal antibodies or human sera was performed after spotting on nitrocellulose εtripε aε previouεly deεcribed (22). Patientε were εkin teεted with GM2, GM2-HSA and KLH at the time of the fifth vaccination. Twenty-five microgramε of each were diluted in 0.05 ml PBS and adminiεtered intradermally. Reεultε were interpreted aε deεcribed previouεly (5) . RESULTS Toxicity The number of vaccinationε administered containing GM2- KLH alone or with various doseε of QS-21 and the local and systemic reactions associated with these vaccinationε iε shown in Table 6. While GM2-KLH alone or with 10 ug of QS-21 resulted, in occasional mild local erythema and induration, increasing doses of QS-21 resulted in increasing frequency and severity of local reactions. At the 10 and 50 ug doses, this waε aεsociated with slight tenderness and 2-4 cm of erythema and induration lasting 24-48 hours (no toxicity greater than grade 1 was detected) . At the higher doses these reactions became more prominent with most reactionε as large as 8-10 cm and some (at the 200 ug dose) extending to 20 cm in diameter. These reactions generally lasted 2-4 days and in one case as long as 7 days at the 100 ug dose, and generally lasted 7 days and in one case as long as 10 days at the 200 ug dose. In no case were analgeεicε more potent than tylenol required and patientε at the 10, 50 and 100 ug doεes continued to pursue their normal activities. Use of the vaccinated extremity was restricted for 5-8 days after administration of the majority of vaccines containing 200 ug QS-21, but all evidence of local reactions had disappeared by two weeks when the patients were next examined. No ulceration and drainage or subcutaneous nodules (aε εeen with moεt other adjuvantε) were detectable. While occasional brief, mild, low grade fevers or myalgias were εeen after vaccinationε containing the lower 3 doses of QS-21, approximately one third of the vaccinations containing 200 ug of QS-21 were asεociated with these symptoms. In general, systemic symptomε were moεt prominent after the second immunization. All patients in the 200 ug QS-21 group were tapered to 100 ug or 50 ug QS-21 for their third and fourth immunizations due to concern over the increasing local and systemic reactions (side effectε for these tapered dose immunizations are listed under 100 ug and 50 ug in Table 6) . Theεe doses were well tolerated and so all 5 patients (one patient had disease progression and was taken off protocol after 4 immunizations) were increased back to 200 ug for the fifth immunization. Two of the five fifth immunizations were associated with fever and flu-like symptoms, one of these was also associated with 20 cm of local erythema and induration. This patient'ε QS-21 dose was decreased to 100 ug in the sixth vaccination, no systemic symptoms developed and the local reaction was mild (3-4 cm erythema and induration) . None of the four remaining sixth immunizations with 200 ug QS-21 were associated with systemic symptoms. While overall the syεtemic symptoms were quite mild, the local erythema, induration and tenderneεε were prominent enough with the 200 ug doεe that applicants chose not to proceed with higher doseε of QS-21. Antibody Response Against GM2 after Vaccinations (see Table 7} Immunization with GM2-KLH alone resulted in antibody titers quite similar to those εeen in previous studies with vaccines containing GM2 adherent to the surface of BCG. Five of 6 patients produced IgM antibody, only 1 patient produced IgG antibody (of low titer) . The IgM antibody titers increased with increasing doses of QS-21. Reciprocal median IgM antibody titer after immunization with GM2-KLH alone was 80, after 10 or 50 ug of QS-21 was 480 and 240 (respectively) , and after 100 or 200 ug of QS-21 was 1280. IgG antibody titers increased progresεively with increaεing doses as well, from 0 in patients receiving GM2-KLH alone to 10, 60, 200 and 640 in patients receiving 10, 50, 100 and 200 ug of QS-21 respectively. Prominent IgM and detectable IgG antibodies (by ELISA and dot blot immune stains) were seen in every patient receiving GM2-KLH plus QS-21. Sequential IgM and IgG antibody titerε for the groupε of six patients receiving the 100 and 200 ug QS-21 doses are shown in Figure 9 * Overall, the antibody response is quite similar in the two groups though IgG ELISA titers were slightly higher with the 200 ug dose. Dot blot immune stains against GM2 confirmed the specificity for GM2 and the similarity of reactions at the 100 and 200 ug doses (see Table 7 and Figure 10) . The median IgM dot blot reaction against GM2 increased from 2+ in patients receiving GM2-KLH alone to between 2+ and 3+ in patients receiving 10 or 50 ug of QS-21 to 3+ in patients receiving 100 or 200 ug of QS-21. IgG reactions increased from 0 in patients receiving no QS-21 to 2+ in patients receiving 10 or 50 ug QS-21, to 3+ in patients receiving 100 or 200 ug QS-21. Specificity Analvsiε of GM2 Antibody Responseε Dot blot immune stains with sera obtained prior to and after immunizationε for 2 representative patients in each of the 5 treatment groups are shown in Figure 10. Prior to immunization, IgM reactivity against GM1 was demonstrated in sera of many patientε aε applicants have previously described, but no reactivity was detected against GM2 or other gangliosides. Following immunization the GM1 reactivity waε not effected but IgM and IgG antibodies against GM2 were seen in all patientε. Aε applicants have previously described (13) , these induced GM2 antibodies sometimeε εhowed croεs-reactivity with GD2 (patient 1, 100 ug dose) . Serological Responses Againεt KLH and QS-21 Aε shown in Table 7, reactivity against KLH waε not seen prior to immunization and increased progressively with increasing doses of QS-21. While the 50, 100 and 200 ug doseε of QS-21 induced significantly higher titers of IgG antibodies against KLH than the 0 or 10 ug dose, there was no significant difference between the serological titers induced at the 50, 100 and 200 ug doses. Antibody titers to QS-21 were assayed by ELISA after four immunizations. There was no significant increase in antibody to QS-21 between pre-and post-immunization serum samples (data not shown) . DTH Responses to GM2 and KLH No erythema or induration were detected at GM2 or GM2-HSA skin test siteε. Prominent erythematouε reactionε were detected at 24 and 48 hourε at most KLH skin test sites and these reactions were largest in patients receiving the 200 ug dose (median diameterε 4.0 by 6.0 cm). These were associated with only minimal induration, suggesting a combination DTH and antibody mediated reaction, making precise quantification of the DTH response (by patients at home) difficult. Further Clinical Trialε Utilizing the εame doεe of vaccine aε above (Biomira, Inc.) six patients with advanced disease were treated. An additional six patients with advanced diεeaεe were treated with 1/10 the GM2-KLH doεe again with 100 μg QS- 21. Antibody titerε in both groupε were lower than seen in patients with early disease but the 7 μg GM2 dose appeared equally as effective at inducing IgM and IgG antibody titerε as the 70 μg dose. In another study, 6 patients with early disease were treated with a GM2-KLH construct. IgG antibody titers were comparable to those seen after administration of the Biomira construct though the IgM antibody titers appeared somewhat lower. However, all patients made antibody following immunization and the vaccine waε well tolerated. A further study will involve 18 patients receiving vaccinations of GM2-KLH, initially at weekly intervals (a schedule shown to be superior in mouse studies) . The patients are randomized, some receiving no pretreatment with low dose cyclophosphamide, and the others receiving pretreatment with low dose cyclophosphamide. At this time 10 patients have been accrued and there appears to be no difference between patients receiving cyclophosphamide and those not receiving cyclophosphamide, and the antibody titers with the new schedule appear at thiε time to be εuperior to thoεe in previouε trialε with the same conjugate. DISCUSSION This was a Phase I trial designed to identify the maximum tolerated dose (MTD) of QS-21 for use in the outpatient setting and the dose of QS-21 providing the greatest immune potentiating effect. The probable MTD was identified as 200 ug QS-21 per vaccination. While the low grade fevers and malaise, and the large local inflammatory reactions at the 200 ug dose, cannot be considered the MTD in the context of high dose IL2 or combination chemotherapy as utilized in hospitalized patients with advanced melanoma (23,24), they were significant in the context of outpatient treatment of cancer patients in the adjuvant setting, and would be unacceptable for immunization againεt infectiouε diseases in normal recipients. The 100 ug dose, however, reεulted in only 2 epiεodeε of low grade fever in 44 injectionε and the local inflammatory reεponses did not interfere with daily activitieε and were generally limited to 2-4 dayε. This dose was well tolerated in the patient population of the clinical trial. There was a clear increase in local and syεtemic toxicity with progression from the 100 ug dose to 200 ug which made us hesitant to continue dose escalations. While fever and malaise at the highest dose were similar to those sometimes seen with other immunological adjuvants such as BCG and DETOX (15,25), local reactions were quite different. The 200 ug dose of QS-21 injected subcutaneously resulted in a 10-20 centimeter diameter area of erythema and induration which was hot and tender to the touch. This local response is more diffuse than the responεe generally seen with doses of DETOX or BCG inducing comparable systemic symptoms. A surprising feature of these reεponses was that several days later (or at most 10 days later) these reactions had completely abated and there waε no evidence that the vaccination had been administered to that sight. No ulceration, drainage or nodule formation at the injection εight waε detected in any patient. A εecond surprising finding in this study was that QS-21 at any of the doses used resulted in a qualitatively different immune responεe to GM2 ganglioεide. Even at the 10 ug dose all patients produced IgG antibodieε detectable by dot blot immune stains against GM2. GM2- KLH vaccines alone or with optimal doεeε of BCG or DETOX, or GM2 adherent to the surface of BCG, salmonella Minnesota mutant R595 or proteosomeε, had only rarely reεulted in more than 1 detectable IgG response per 6 immunized patients (2,4,5). IgM and IgG antibody titers against GM2 continued to increase with increasing doses of QS-21 but appeared to reach a plateau between the 100 and 200 ug dose. IgG antibodies against KLH likewise increased with increasing doεes of QS-21. Peak IgG titers were significantly higher at the 50, 100 and 200 ug doses than at the 0 or 10 ug doεeε, but the titerε at the three higher doεeε were not significantly different from each other. Resultε demonstrate that the 100 and 200 ug doses of QS-21 induce the optimal antibody response against GM2 and that the 100 ug dose is better tolerated. The primarily erythematous skin test responses against KLH in patients immunized with GM2-KLH alone or GM2-KLH plus various doseε of QS-21 was unexpected. It may represent a combination of antibody mediated arthus-like and DTH responses. It is also possible that the lower dose of KLH in the skin tests than that used in studies by others (26) (25 ug as opposed to 100 ug) was insufficient to produce a strong detectable DTH reaction, or that the high epitope density of GM2 ganglioside on the KLH in the vaccines did not permit the normal antigen processing and presentation required for induction of a classical DTH response against KLH. Despite the wide spread use of QS-21 and other saponin containing adjuvants in experimental animals and veterinary practice (14-19) , their mechanism of action remains unknown. It is possible to make some inferences on the mechanism of action of QS-21 from these studies. The lack of palpable nodules at injection sights suggest that a depo effect with granuloma formation does not occur. Despite the potency of QS-21 as an adjuvant, it appears to be a poor immunogen. Even after repeated immunizations, no detectable antibody responses resulted. So unlike other adjuvantε εuch aε C parvum, BCG and complete Freund'ε adjuvant, the immunogenicity of QS-21 may not contribute to itε adjuvant effect. Low grade fever and malaise seen at the 200 ug dose, and diffuse erythema and induration at injection sightε, suggest that cytokine release is involved. Intradermal injection of IL-2 has resulted in very similar reactions which on biopsy are characteristic of clasεical DTH reεponses (27,28). Partial switching of GM2 antibodies to an IgG response suggests induction of T cell help, perhaps as a consequence of this cytokine induction. Applicants have recently demonstrated the superiority of KLH over other carriers tested for augmentation of ganglioside immunogenicity (12) and applicantε demonstrate here the optimal dose of QS-21 for further augmentation of this effect. As applicants prepare for a large phase III trial of ganglioside vaccine in AJCC stage III melanoma patients, there are a number of variables which remain to be tested. Applicantε are currently conducting preclinical εtudieε with thiε ganglioside-KLH plus QS-21 vaccine plus the use of several other immunological adjuvants. In addition, clinical trials with different scheduleε of immunization and different doses of GM2-KLH are .planned. The surprising findings in the phase I trial deεcribed here are 1) no evidence of granuloma formation was detected at any dose of QS-21 and 2) that at the well tolerated dose of 100 ug, the serological response against GM2 was strikingly superior, quantitatively and qualitatively, to any seen with previously tested GM2 vaccines. TABLE 6 NUMBER OF ADVER8E REACTIONS OCCURRING (AND THEIR SEVERITY) AT EACH QS-21 DOSE IN PATIENTS RECEIVING VACCINES CONTAINING 500 UG GM2-KLH + Q8-21 Dose of QS-21 and Adverse Reactions 0 10 ug 50 ug 100 ug 200 ug Number of Vaccinations 35 22 34 44 23 ADVERSE REACTIONS: Local Tenderness and Pain 6(1) 7(1)* 21(1) 34(2) 23(2) Erythema and Induration 6(1) 4(1) 17(1) 24(2) 21(3) Systemic Fever 0 0 3 ( 1 ) 2 ( 1) 7 ( 1) Headache 0 0 0 0 1 ( 1) Myalgia 0 i d) 2 ( 1 ) 0 6 ( 1) Nausea or Vomiting 0 i d) 1 ( 1 ) 0 1 ( 1) 7(1): Local pain or tenderness was experienced after 7 of 22 vaccinations containing 10 ug QS-21. The number in parenthesis indicates median severity by the NCI Common Toxicity Criteria, in this case mild local tenderness. For local toxicity, (1) Minimal tenderness and erythema, (2) Moderate erythema and induration <10 cm, pain not requiring narcotic analgesicε, (3) Erythema and induration > 10 cm, pain requiring narcotic analgesics (not seen) . For systemic toxicity, (1) refers to temperatures 101°-103°F, mild headaches, mild muscle aches or mild nausea with no vomiting. TABLE 7 SEROLOGIC RESPONSE AFTER VACCINATION WITH GM2-KLH PLU8 VARIOUS DOSES OF QS-21 VACCINE # OF PEAK ELISA TITER AGAINST GM2 PATIENTS GM2-KLH PLUS Pretreatment After Treatment IgM IgG IgM IgG No adjuvant 6 20,0(5) * 0(6) 160(2) ,80(2) , 40,0(5) 40,0 10 μg QS-21 4 0(4) 0(4) 1280,640,320,80 80,20,0(2) 50 μg QS-21 6 20,0(5) 0(6) 640,320(2) ,160(3) 80(3) ,40(2) ,20 100 μg QS-21 6 40,0(5) 0(6) 5120,1280(3) ,160,80 2560,640,320,80,40(2 200 μg QS-21 6 320,20, 0(6) 5120,1280(3) ,320(2) 1280(2) ,640(2) , 0(4) 320,80 TABLE 7 - Continued PEAK DOT BLOT IMMUNE SYSTEM IgG ELISA TITER AGAINST KLH RESPONSE AGAINST GM2 VACCINE # OF PATIENTS GM2-KLH PLUS IgM IgG Pretreatment After Treatment No adjuvant 6 3+,2+(3) ,l+,0 l+(2),0(4) 0(6) 360,180(3) ,20(2) 10 μg QS-21 4 3+(2),2+(2) 2+(3) ,1+ 0(4) 810,270(2) ,90 50 μg QS-21 6 3 + (3) ,2+(3) 3+(2),2+(2), 0(6) 2430(3) ,810(2) ,90 l+(2) ^ ^ 100 μg QS-21 6 3+(5) ,2+ 3+(4),2+(2) 0(6) 21,870,2430(3) ,810(2) 200 μg QS-21 6 3+(4),2+(2) 3+(4),2+(2) 0(6) 21,870,7290(3) ,2430,810 * One patient had a pretreatment peak titer ELISA response of 1/20. The number parenthesis indicates the number of patients with a given response. In this case, fiv patients had no detectable GM2 antibodies. Fifth Series of Experiments INTRODUCTION The incidence of malignant melanoma haε increased rapidly over the last decade. In 1992, over 32,000 individuals in the United States developed melanoma, and 6,700 deaths from melanoma were recorded (1) . Following adequate resection of primary melanoma the five-year εurvival rate ranges from greater than 95% for patients with primary tumors of < 0.75 mm thicknesε to 50% for those with primary tumors of > 4.0 mm thicknesε (2). Patientε with regional lymph node metaεtaεeε (AJCC Stage III) , have a 5 year εurvival of 25-35% after elective or therapeutic dissection (3) . No adjuvant therapy has been shown to reduce the rate of recurrence and increase survival after surgery in these patients. A large variety of agents have been tested in these adjuvant trials (reviewed in refs. 4, 5) including chemotherapy, nonspecific immune stimulators, interferons, and various types of melanoma vaccineε. With regard to melanoma vaccineε, the challenge has been to develop methodε that can monitor immunogenicity of the vaccineε in terms of strength and specificity of the reεulting immune response. Because humoral immune reactions to vaccines can be quantitated and analyzed with a precision that is only now becoming possible with cellular immune reactions, applicants have focuεed on melanoma antigenε that elicit humoral immunity. Of theεe εerologically defined antigenε, ganglioεideε, particularly GM2, have emerged aε attractive targets for active immunization (5-8) . Applicants have recently shown that immunization with purified GM2 adherent to BCG, after pretreatment with low dose Cy, resulted in the induction of IgM antibodieε in a high percentage of melanoma patients (8,9). The GM2 antibody response showed a T-cell independent pattern, i.e., short duration, lack of an IgG response, and lack of a booster effect of repeated vaccinations. The induced antibodies were cytotoxic for GM2-expressing melanoma cells in the presence of human complement, and patients that produced GM2 antibodies after immunization showed significantly longer disease-free interval and survival than patients that did not (9) . The purpose of the present study was to confirm the beneficial effectε of vaccine-induced GM2 antibody production in a randomized controlled trial. Materials and Methods Patients Patients with pathologically documented melanoma metastases restricted to regional skin and lymph nodes (AJCC Stage III) were eligible for a period of 2 weeks to 13 weekε after complete resection of skin metastases or regional lymph nodes. Other eligibility criteria included: age >15 yearε; Karnofεky performance status > 90; serum creatinine < 2.5 mg/dl, serum bilirubin < 2.5 mg/dl; no other cancers; no chemotherapy or radiation therapy during the 8 week period preceding vaccination. Pregnant women were excluded. All patients were examined, and eligibility determined, within two weeks prior to randomization. Subsequent clinical follow-up was performed by the patient , ε primary oncologiεt. Randomization and Follow-up Informed conεent was obtained from all patients and they were stratified by number of positive lymph nodeε (l, 2- 4 » 5) , preεence of intransit diseaεe, and interval between surgery and vaccination (2-6 weeks, 7-13 weeks). Patients were randomized by computer (with adaptive allocation of block sizes to enεure reasonably even numbers in the two arms) to be vaccinated with GM2/BCG or with BCG alone. Neither patients nor medical personnel were informed of the type of vaccine administered until two weeks after the final vaccination. Follow-up information on all patients was obtained over a one-week period every 4-6 months by telephoning their primary physicians. Dates of recurrence documented radiographically or pathologically were used for determining disease-free interval. Since the two nonspecific components of this vaccination approach, BCG and low-doεe cyclophoεphamide, may have demonstratable anti-tumor activity (10,11,12) , they were considered more appropriate than no treatment for the control arm. GM2/BCG Vaccine The ganglioside GM2 used for vaccine production was obtained from two sources, brain tisεue from catε with Tay-Sachε diεease (transmitted in these cats as an autoεomal receεεive trait) , and GM1 prepared from brains of domestic cowε and purchaεed from Supelco, Beliefonte, PA. Sliceε of Tay-Sachε cat brain (provided by Dr. Mario Ratazzi, Mt. Sinai Hospital, New York, NY) were extracted with chloroform/methanol, and the extract was peracetylated, εubjected to floriεil chromatography to remove phospholipids, deacetylated, dialyzed and subjected to DEAE-Sephadex column chromatography (13) . After dialysiε, GM2, the major fraction, waε separated by preparative thin layer chromatography. GM2 was prepared from bovine brain GM1 by cleavage of the terminal galactoεe uεing β-galactoεidaεe, aε previouεly deεcribed (14) . GM2 from the two sources was indistinguishable by thin layer chromatography (TLC) and immune TLC using murine monoclonal antibodies recognizing GM2 (13) . Each batch of GM2 was more than 98% pure as defined by thin layer chromatography and densitometric scanning. Batches were tested by standard tests for sterility, and for safety in guinea pigs and mice. Purified GM2 was dried and stored at 4°C. Tice strain BCG (University of Illinois, Chicago, IL) , 10 7 viable units (or 3 x 10 6 viable units for use in patients with a positive PPD test) was suspended in distilled water by sonication together with 200 ug of dried purified GM2. The suspension was lyophilized and stored at -80°C. The residue was resuspended in 0.5 ml phosphate-buffered saline (PBS) shortly before vaccine administration. Under these conditions, GM2 has been found to adhere to BCG, presumably by hydrophobic bonds, as applicants have previously reported (8) . BCG was suspended in PBS for use in the control group. All patients in the GM2/BCG group received 200 ug GM2 per vaccination. These vaccines and the vaccination protocol were approved by the Memorial Hospital Institutional Review Board and used under an IND with the U.S. Food and Drug Administration. The initial patients received GM2 of cat brain origin. Subsequently, an increasing proportion of GM1 derived GM2 was used because cat brain GM2 was no longer available. All patients received intradermal vaccine injections into 6-10 siteε of an extremity with intact lymphatic drainage, and thiε waε repeated twice at two-week intervals, using different extremities each time. Booster immunizations were administered two and five months after the initial serieε of vaccinationε. Cy Adminiεtration A single dose of 200 mg/M 2 Cy (Cytoxan; Mead Johnson and Co. , Evansville, IN) was administered intravenously to all patientε five to seven days prior to the first and fourth vaccine injections. Ganglioside Reagents GD2 waε prepared by treating GDlb with β-galactosidase (G.W. Jourdian, University of Michigan, Ann Arbor, MI) according to published methods (14) . GM1 waε purchased from Supelco (Beliefonte, PA) . GD3 was a gift from Fidia Research Laboratories (Abano Terme, Italy) , and GDlb was purchased from the same source. GM3 was purified from dog erythrocytes (13) . GM2 for dot blot immune stainε (Figure 11) waε prepared from GM1 by treatment with β-galactoεidaεe or extracted from human melanoma biopεy εpecimenε aε previously described (13) . Serological Procedures Sera were obtained at the time of each vaccination, 2 and 6 weeks after vaccines 3, 4 and 5, and 3 months after vaccine 5. The ELISA for GM2 or BCG antibodies (9) was performed with patient sera and rabbit anti-human IgM or anti-human IgG second antibody, or Protein A conjugated with alkaline phosphatase (Kirkegaard and Perry Labs, Gaithersburg, MD) . Readings obtained with normal sera from donorε without GM2 reactivity were εubtracted from readingε obtained with the patientε' sera. Antibody titer was defined as the highest serum dilution yielding a corrected absorbance of > 0.10 as previously described (9) . Dot blot immune stains were performed as previously described (8,9), and graded 0, 1+, 2+ or 3+ as shown in Figure 11. Sera were categorized as positive if GM2 reactivity was 2+ or 3+ by dot blot with ELISA titer > 1/20 or 1+ by dot blot with an ELISA titer > ^ 1/80. Complement dependent cytotoxicity aεεays were performed as previously deεcribed with normal human εerum (diluted 1/3) aε complement source and visual quantification of nonviable cells by Giemsa stain (8,15). Skin Tests for Delaved-Type Hypersensitivity (DTH) Unilamellar liposomes were prepared from egg phosphatidyl choline and passed through a 0.1 micron filter ten times. On the day of skin testing, (2 weeks after the fourth vaccination) 1.5 mg phosphatidyl choline liposomes and 25 ug GM2 were mixed in PBS and sonicated in a Branson 1200 water bath sonicator (Shelton, CT) . Skin tests (0.1 ml volume) with a) 25 ug GM2 and b) 25 ug/1.5 mg GM2/liposomes were performed and read at 48 hours as previously described (16,17). RESULTS Patient Characteristics A total of 123 patients were enrolled between March 10, 1987 and March 17, 1989. On review, one patient was found to have AJCC Stage II diseaεe (no poεitive lymph nodeε) and waε therefore not included in the analyεis. All 122 eligible patients, regardless of the number of vaccines received, are included as randomized in the analysis. Two patients (one in each group) decided to leave the study after one immunization because they found it too difficult to deal with the uncertainty of experimental therapy and randomization. One patient in the BCG group had received only two immunizations when disease progresεion waε detected, and the treatment waε discontinued. All other patients received at least the initial series of three immunizations and remained on protocol until its completion or until disease progression. One patient in the BCG group accidentally received GM2/BCG in the fifth vaccination (he produced GM2 antibody and remained free of disease) . The median follow-up iε five yearε and three monthε, with a minimum follow-up of four years and three months after pre- randomization surgery. The characteristics of the 122 randomized patients are shown in Table 8. The single most important prognostic indicator for patients with Stage III melanoma is the number of positive lymph nodes (3) . Other factors associated with a poor prognosis include head and neck or trunk as the primary site, and intransit melanoma (3) . The GM2/BCG and BCG groups were comparable with regard to theεe prognoεtic indicators. TABLE 8 PATIENT CHARACTERISTICS CHARACTERISTIC TREATMENT GROUP GM2 ANTIBODIES BCG GM2/BCG Positive Negative No. of Patients 64 58 64 58 Sex (M/F) 48/16 37/21 48/16 37/21 Median Age 48.5 46 49.5 44 (Range) (27,75) (16,74) (31,75) (16,74) Time Since Surσerv 14-42 days 21 22 20 23 43-91 days 43 36 44 35 Primary Site Head and Neck 7 7 8 6 Trunk 29 24 28 25 Extremity 23 17 21 19 Not Detected 5 10 7 8 Depth of Primary < 2mm 15 12 15 12 2-4 mm 20 15 19 16 > 4mm 10 11 10 11 Not Available 19 20 20 19 Intranεit Disease Absent 54 52 54 52 Present 10 6 10 6 Number of Lvmph Nodes with Metastases 1 27 24 26 25 2-4 23 23 24 22 > 4 14 11 14 11 Side Effects Pretreatment with Cy occasionally resulted in mild nausea or gueasiness for 2-24 hourε but waε mostly well tolerated. Intradermal injection of BCG resulted in inflammation and eschar formation with drainage in all patients receiving three or more immunizations. To keep the inflammatory response at an acceptable level, the dose of BCG was decreased by a factor of 3 when eschar formation or drainage was first detected. Consequently, the median BCG dose at the time of the final immunization was 3 x 10 6 viable units in both treatment groups. The dose of 10 7 unitε waε maintained in only 10% of patients, and some patients required a further dose reduction to 10 6 units. GM2 had no effect on the inflammatory responεe to BCG and caused no additional side effects. Serological Response Against GM2 Sequential IgM anti-GM2 antibody titers before and after vaccination with GM2/BCG are shown in Figure 10 for the first five patients treated (in 1987) and the last five patients treated (in 1989) who received the full series of GM2/BCG immunizations. Aε in a previouε study (9) , the antibody response was predominantly of the IgM type, and frequently showed an increase in titer after each immunization that resembled a repetitive primary response rather than an amnestic secondary response. Pre- immunization and peak titer post-immunization sera from all patients were also tested by dot blot immune stain to confirm the specificity of the antibodies detected by ELISA. Dot blot immune stainε with the ten sera shown in Figure 10 are shown in Figure 11. Occasional low-titer pretreatment reactivity against GMl was detected as previously described (8,9). Vaccine induced reactivity was restricted to GM2; no reactivity waε εeen with GM3, GD2, GDlb or GD3. GM2 antibodieε were able to mediate complement dependent cytotoxicity in tests on GM2 expressing tumor cells with human complement (Table 9) . No change in this pattern of antibody response and specificity was seen over the two year period of patient accrual. The results of serological analysis for all patients are summarized in Table 10. Seven of the 64 patientε in the BCG arm were found to exhibit GM2 antibodieε both by ELISA (median titer 1/40) and dot blot immune stain (median 2+) . The antibodieε were preexisting in 5 caseε and were first detected after BCG vaccination in 2 caseε. Titerε of GM2 antibody increaεed 4-fold or more after BCG immunization in 3 of 5 patients with GM2 antibody prior to BCG vaccination. In contrast, only one of the 58 patients receiving GM2/BCG exhibited GM2 reactivity by both assays before immunization and 50 of 58 patients showed GM2 antibodies (median ELISA titer 1/160) in their serum after immunization, confirmed by dot blot immune stain (median titer 3+) . The overall IgM anti-GM2 serologic response rate (2+ or 3+ dot blot and ELISA titer > 1/20 or 1+ by dot blot and ELISA titer > 1/80) in the two groups was 11% for BCG alone and 86% for GM2/BCG. IgG antibodies were not detected in any patient's serum prior to immunization and were not induced in any patient by BCG immunization (Table 10) . Vaccination with GM2/BCG induced a positive IgG antibody response in eight patients (median ELISA titer 1/80, median dot blot 2+) . Theεe reεponses were short-lived (median duration 8 weekε) and did not generally increaεe with additional immunizationε. IgG reactivity in all cases was restricted to GM2 (data not shown) . All eight patients also had IgM antibodies which were of higher titer and longer duration than the IgG antibodies. TABLE 9 COMPARISON OF GM2 ANTIBODY TITERS BEFORE AND AFTER IMMUNIZATION GM2/BCG, AS DETERMINED BY ELISA AND CYTOTOXICITY TESTS WITH HUMAN COMPLEMENT PATIENT IgM ELISA O.D. AT 1/40 CYTOTOXICITY TITER * TITER SERUM 20% LYSIS 50% LYSIS DILUTION Endpoint Endpoint 20 0.05 20 0 160 0.412 20 0 0 0.066 5 0 80 0.134 80 5 0 0.017 0 0 320 0.78 80 5 10 10 0.057 0 0 160 0.455 80 20 12 0 0.011 5 0 160 0.506 320+ 20 53 0 0.004 20 0 320+ 0.896 320+ 320 54 0 0.000 5 0 160 0.387 20 5 56 0 0.013 20 0 320 0.418 320 20 57 0 0.028 80 20 640 0.811 320 80 58 0 0.029 5 0 320 0.718 320 20 Target cellε: aεtrocytoma cell line SK-MG 6, TABLE 10 GM2 ANTIBODIES IN THE SERUM OF MELANOMA PATIENTS BEFORE AND AFTER IMMUNIZATION WITH GM2/BCG, OR BCG VACCINES TOTAL NO. NO. OF PATIENTS WITH NO. OF PATIENTS WIT VACCINE PATIENTS ELISA TITER (RECIPROCAL) DOT BLOT IMMUNE STAI 0 10 20 40 80 160 320 640 0 1+ 2+ 3 IgM ANTIBODIES GM2/BCG BEFORE VACCINATION 58 35 11 10 1 1 56 1 1 AFTER VACCINATION 58 2 3 2 8 8 15 11 7 4 15 3 BCG BEFORE VACCINATION 64 40 10 8 4 2 57 2 5 AFTER VACCINATION 64 26 11 14 7 4 1 57 2 3 IgG ANTIBODIES GM2/BCG BEFORE VACCINATION 58 58 58 AFTER VACCINATION 58 48 3 1 47 BCG BEFORE VACCINATION 64 64 64 AFTER VACCINATION 64 64 64 DTH Response to GM2 Skin tests for DTH against GM2 and other antigens were performed after the initial series of three vaccinations. All patients receiving three or more immunizations developed strong DTH reactions to BCG. Eight patients (four vaccinated with BCG and four vaccinated with GM2/BCG) showed positive DTH reactions to GM2 and GM2 liposomes (used to keep GM2 at the skin test site) ranging from 10 to 33 mm of induration. Further tests revealed that these 8 patients εhowed εimilar reactivity with ganglioεide free lipoεomeε and with other gangliosides. Thus, there was no evidence for GM2 specific DTH in any patient. Serologic Response Against BCG Sera from all patients were tested for IgG ELISA reactivity against 10 3 viable organisms/we11 BCG dried onto ELISA plates aε described for gangliosides. No reactivity was seen before vaccination. Post-vaccination sera showed BCG antibody titers of 1/40-1/80 in both treatment groups, independent of whether or not the patients produced GM2 antibodies. Correlation of Antibody Responεe and Immunization with Disease-Free Interval and Survival Comparison of diseaεe-free interval and overall survival for all patients producing GM2 antibodies documented by two asεayε (ELISA titer of > 1/180 and dot blot 1+ or ELISA titer > 1/20 and dot blot > 2+) with those of patients who did not produce GM2 antibody is shown in Figure 12. Significant differences were seen in both disease-free interval and overall εurvival (p= .004 and .02 respectively, by log rank test). Of the six patients who produced GM2 antibody prior to immunization (five receiving BCG and one receiving GM2/BCG) , only one (a patient in the BCG group) developed recurrent disease, suggesting that the natural production of GM2 antibodieε in patients with melanoma is associated with a favorable course. Conversely, of the eight patients who did not produce GM2 antibodies after vaccination with GM2/BCG, six developed recurrent melanoma and died, suggesting that failure to produce GM2 antibodies after vaccination indicates an unfavorable prognosis. Median BCG antibody titers in the six patients producing natural GM2 antibodies were the same as the titers in the eight GM2 antibody-negative patients in the GM2/BCG arm, indicating that these patients did not differ in their ability to mount a serologic responεe to an unrelated antigen. When the six patients producing GM2 antibodies prior to randomization (five in the BCG arm and one in the GM2/BCG arm) were excluded from the analysis, disease-free interval of the GM2/BCG group was significantly longer than that of the BCG group (p = .02 by logrank test) , and a trend toward longer overall survival was also observed for the GM2/BCG group (Figure 13). The curves plateau at 40-52 months, with differences of 23% and 14% in disease- free interval and overall survival, respectively. The small number of patients producing IgG antibodies reactive with GM2 after immunization makeε it impossible to draw conclusion about the relative merits of IgM and IgG antibodies againεt GM2. Five of the eight patientε poεitive for IgG GM2 antibodieε remain free of disease at this time. Comparison of the two treatment groups as randomized is shown in Figure 14. The curves plateau at 40 to 52 months with a 18% difference in disease-free interval and 11 % difference in overall survival in favor of vaccination with GM2/BCG. These differences were not statistically significant. Disease-free interval (30%) and overall survival (46%) rates at 51 monthε (the minimum period of follow-up) in the BCG group are similar to the rates applicants observed earlier in patients randomized to receive BCG or no treatment (28) . As shown in Figure 14, a beneficial effect of immunization was more evident when the two treatment groups were stratified for number of positive nodes (1 versus 2 or more) . Immunization had less impact on diseaεe free interval rateε in patientε with only one poεitive node. In contraεt, the disease-free interval of patients with two or more positive nodes who received GM2/BCG was significantly longer than that of patients immunized with BCG alone (p = .02 by logrank test) . A similar trend was seen for survival (p = .08 by logrank test). DISCUSSION Applicants have made conεiderable efforts to develop ganglioside vaccineε that induce high levelε of serum antibodies (18,19) because 1) gangliosides are major cell surface constituents of melanoma cells (14,20-25), 2) human monoclonal antibodieε with specificity for gangliosides can be isolated with relatively high frequency from patients with melanoma (14,25-28) and 3) human tumor cells expresεing ganglioside antigens can be lysed by anti-ganglioside antibodieε in the preεence of human complement (13,29). GM2 ganglioεide had been found particularly immunogenic in humanε, and vaccineε containing purified GM2 and BCG aε adjuvant have been shown to elicit GM2 antibodies in melanoma patients pretreated with low dose cyclophosphamide (8,9). The study reported here was intended to answer two questions does vaccination with a GM2/BCG vaccine induce production of GM2 antibodieε in a high percentage of melanoma patients and does induction of GM2 antibodies alter the course of the disease in patients with Stage III melanoma after complete resection of all known tumor? Regarding induction of GM2 antibodies, immunization with GM2/BCG was clearly effective in the majority of patients. Of 58 patients receiving the GM2/BCG vaccine, 50 produced GM2 antibodies detected in both ELISA and dot blot immune stain assays. As in earlier experience (9) , the induced GM2 antibodies were moεtly of the IgM class; IgG antibodies were detected lesε frequently. The correlation between GM2 antibody production and a more favorable clinical course (9) was also confirmed here and expanded in a more homogeneous population of disease-free AJCC Stage III melanoma patients. Patients producing GM2 antibody (whether naturally occurring or vaccine induced) had a εignificantly longer disease-free and overall survival than patients who showed no antibody response. Preexisting GM2 antibody (prior to vaccination) was seen in six patients in this series and appeared to be associated with an especially favorable prognosis. As the incidence of spontaneouε GM2 antibody production appearε to be εimilar (10%) in the general population and in melanoma patientε (8,9), their relationship to melanoma development and growth remains unknown. It iε of note that the titer of preexisting GM2 antibodies did not change over the nine-month follow-up period, whereas vaccine-induced GM2 antibodies generally remained detectable for only 8-12 weeks after immunization. This observation raiseε the poεεibility that persistence of antibody production may be important for a favorable clinical outcome and it indicates the need for developing G M2 vaccines that produce long lasting GM2 antibody responses. In contrast to vaccinated patients developing GM2 antibody, the 8 patients who did not produce GM2 antibody after immunization with GM2/BCG showed particularly rapid disease progresεion, recurrence being detected usually before the complete series of five immunizations was administered. Other prognostic factors were not less favorable in these patients, nor was their antibody response to BCG less vigorous than the response in GM2 antibody positive patients, indicating that general immunosuppresεion is not the underlying mechanism. An asεociation between GM2 antibody production and improved prognoεiε haε also been suggested in studies of the antigen designated OFA-I (31) , a cell surface antigenic system expresεed by many melanomas. Several lines of evidence have indicated that antibody reactivity against OFA iε primarily directed against GM2 ganglioside (30,25). Patientε with increaεed IgM titerε againεt OFA- I, either preexisting or after immunization with irradiated melanoma cells, showed prolonged survival (31). While adding strength to the argument that GM2 antibodieε are associated with a favorable prognosis in patients with melanoma, this study also illustrateε the problemε that emerge in deεigning randomized vaccine trialε. Preexiεting GM2 antibody production in 5 patientε in the control group aε oppoεed to 1 patient in the GM2/BCG group, and lack of a GM2 antibody reεponεe in 8 vaccinated patientε in the GM2/BCG group contributed to a blunting of the diεtinction between the two randomized treatment groupε to a point that the therapeutic gain in the GM2/BCG group waε not εignificant. Clearly, patients with preexisting antibodies to GM2 need to be excluded or at least stratified in future studies. Equally important iε the need to increase the immunogenicity of the vaccine. In thiε regard, applicants have explored approaches that have been succesεfully pursued in the context of carbohydrate vaccines against bacterial infections (reviewed in 32) , including chemical modification of gangliosides to yield closely related congeners (33,34), ganglioside conjugation with immunogenic protein carrierε (35) , and use of more potent adjuvantε (36) . The approach applicantε have found most effective has been to conjugate GM2 with keyhole limpet hemocyanin (KLH) and to administer the GM2-KLH conjugate with QS-21 (a saponin extract from Saponaria Quillaja) as adjuvant. In a pilot study in patients with melanoma, administration of this vaccine resulted in IgM GM2 antibody titerε much higher than thoεe εeen after GM2/BCG and, even more important, consistent production of GM2 antibodies belonging to the IgG class, thus apparently converting a T-independent antibody response into a T- dependent response (37) . An additional approach to improving the clinical efficacy of the GM2/BCG vaccine described here would be incorporation of additional immunogenic melanoma gangliosides into the vaccine. Experiments in the mouse indicate that conjugation with KLH and use of QS-21 adjuvant also augments the immunogenicity of GD3 (35) , a more highly expresεed melanoma ganglioεide that haε εo far shown very low immunogenicity in patients with melanoma. If these observations can be confirmed in human studies, applicants may have the basis for constructing a polyvalent ganglioεide conjugate vaccine incorporating εeveral major melanoma ganglioεideε, and thuε circumventing the heterogeneity of ganglioεide expression seen in human melanomas. Applicants believe that the results of the study reported here justify further pursuit of this approach. References of First and Second Series of Experimentε 1. Apple, R.J. , Domen, P.L., Muckerheide, A. & Michael, J.G. (1988) . Cationization of Protein Antigenε: IV Increased Antigen Uptake by Antigen Presenting Cells. J. Immunol . 40: 3290. 2. Berd, D., Mastrangelo, M.J. , Engstrom, P.F., Paul, A. and Maguire, H. (1982) Augmentation of the human immune response by cyclophosphamide. Cancer Res . 42: 4862. 3. Borch, R.F., Bernstein, M.D. and Durst, H.D. (1971). The cyanohydridobroate anion aε a εelective reducing agent. J. American . Chem . Soc . 93:2897. 4. 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Claims: What is claimed is: 1. A vaccine for stimulating or enhancing in a subject to which the vaccine is administered, production of an antibody which recognizes a ganglioside, comprising an amount of ganglioside or oligosaccharide portion thereof conjugated to an immunogenic protein effective to stimulate or enhance antibody production in the subject, an effective amount of adjuvant and a pharmaceutically acceptable vehicle. 2. The vaccine of claim 1, wherein the subject is a human. The vaccine of claim 1, wherein the ganglioside or oligosaccharide portion thereof iε conjugated to Keyhole Limpet Hemocyanin or a derivative of Keyhole Limpet Hemocyanin. The vaccine of claim 3, wherein the adjuvant is QS- 21. 5. The vaccine of claim 3, wherein the ganglioside is selected from the group conεisting of GM2, GM3, GD2, GD3, GD3 lactone, O-Acetyl GD3 and GT3. 6. The vaccine of claim 3, wherein the ganglioside is GM2. 7. The vaccine of claim 3, wherein the ganglioside is GD3. 8. The vaccine of claim 5, wherein the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is an amount between about 1 μg and about 200 μg. 9. The vaccine of claim 8 wherein the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is an amount between about 50 μg and about 90 μg. 10. The vaccine of claim 9 wherein the effective amount of conjugated ganglioside or conjugated oligosaccharide portion thereof is about 70 μg. 11. The vaccine of claim 8 wherein the effective amount of conjugated ganglioside or conjugated oligoεaccharide portion thereof iε between about 1 μg and about 10 μg. 12. The vaccine of claim 11 wherein the effective amount of conjugated ganglioεide or conjugated oligosaccharide portion thereof is about 7 μg. 13. The vaccine of claim 5, wherein the adjuvant is QS- 21. 14. The vaccine of claim 4, wherein the effective amount of QS-21 is an amount between about lOμg and about 200 μg. 15. The vaccine of claim 14 wherein the effective amount of QS-21 is about 100 μg. 16. The vaccine of claim 14 wherein the effective amount of QS-21 is about 200 μg. 17. The vaccine of claim 6, wherein the adjuvant is QS- 21. 18. The vaccine of claim 1, wherein the subject is afflicted with cancer and the antibody produced in the subject upon administration of the vaccine effectively treatε the cancer. 19. The vaccine of claim 1, wherein the subject is susceptible to cancer and the antibody produced in the subject upon administration of the vaccine effectively prevents the cancer. 20. The vaccine of claim 18 wherein cells of the cancer have gangliosideε on their surface. 21. The vaccine of claim 19, wherein, cells of the cancer have ganglioεideε on their εurface. 22. The vaccine of claim 18, wherein ganglioεideε are found in the εtroma of the cancer. 23. The vaccine of claim 19, wherein ganglioεideε are found in the εtroma of the cancer. 24. The vaccine of claim 18, wherein the cancer iε of epithelial origin. 25. The vaccine of claim 19, wherein the cancer iε of epithelial origin. 26. The vaccine of claim 18, wherein the cancer iε of neuroectodermal origin. 27. The vaccine of claim 19, wherein the cancer is of neuroectodermal origin. 28. The vaccine of claim 26, wherein the cancer of neuroectodermal origin iε a melanoma. 29. The vaccine of claim 27, wherein the cancer of neuroectodermal origin iε a melanoma. 30. A method for stimulating or enhancing in a subject production of antibodies which recognize a ganglioside comprising administering to the subject an effective dose of the vaccine of claim 1. 31. The method of claim 30 wherein the ganglioside is GM2. 32. A method for treating cancer in a subject afflicted with cancer comprising administering to the subject an effective dose of the vaccine of claim 18. 33. A method for preventing cancer in a subject susceptible to cancer comprising administering to the subject an effective dose of the vaccine of claim 19. 34. The method of claim 30, 32 or 33, wherein the ganglioside or oligosaccharide portion thereof is conjugated to Keyhole Limpet Hemocyanin or a derivative of Keyhole Limpet Hemocyanin. 35. The method of claim 34, wherein the adjuvant is QS- 21. 36. The method of claim 32 or 33, wherein cells of the cancer have gangliosideε on their εurface. 37. The method of claim 32 or 33, wherein ganglioεideε are found in the stroma of the cancer. 38. The method of claim 32 or 33, wherein the cancer is of epithelial origin. 39. The method of claim 32 or 33, wherein the cancer is of neuroectodermal origin. 40. The method of claim 39, wherein the cancer of neuroectodermal origin is a melanoma. 41. The method of claim 30 wherein the adminiεtering comprises administering at two or more sites. 42. The method of claim 41 wherein the administering comprises administering at three sites. 43. The vaccine of claim 3, wherein the ganglioside is GD3.

Inventors: HELLING FRIEDHELM, LIVINGSTON PHILIP O, HELLING, FRIEDHELM, LIVINGSTON, PHILIP, O.
Applicants: HELLING FRIEDHELM, LIVINGSTON PHILIP O, SLOAN KETTERING INST CANCER, HELLING, FRIEDHELM, LIVINGSTON, PHILIP, O., SLOAN-KETTERING INSTITUTE FOR CANCER RESEARCH
Application year: 1994
Main classification: A61K45
IPC codes: A61K31, A61K39, A61K45, A61K47, A61P35